North karelia

Pekka PuskaPekka PuskaDirector GeneralDirector GeneralNational Public Health Institute – KTLNational Public Health Institute – KTLHelsinki, FinlandHelsinki, Finland

FOOD AND PUBLIC HEALTHFOOD AND PUBLIC HEALTH

NORDIC FOOD WEEK, NORDIC FOOD WEEK, St. Petersburg 19.9.2007 St. Petersburg 19.9.2007

NORDIC FOOD WEEK 19.9.2007 2



Global Public Health Global Public Health in in TransitionTransition

Chronic diseases – especially Chronic diseases – especially cardiovascular diseasescardiovascular diseases

Leading health problem in Leading health problem in industrialized countriesindustrialized countries

Main killers and rapidly growing Main killers and rapidly growing problem in developing countriesproblem in developing countries


Projected Main Causes of Death,Projected Main Causes of Death,Worldwide, All Ages, 2005Worldwide, All Ages, 2005

NORDIC FOOD WEEK 19.9.2007NORDIC FOOD WEEK 19.9.2007


NCDs are to a Great Extent NCDs are to a Great Extent Preventable DiseasesPreventable Diseases

Medical evidence for prevention exists.Medical evidence for prevention exists.

Population-based prevention is the most Population-based prevention is the most cost-effectivecost-effective and the only and the only affordableaffordable option option for major public health improvement in NCD for major public health improvement in NCD rates.rates.

Major changes in population rates can take Major changes in population rates can take place in a surprisingly place in a surprisingly short time.short time.

Diabetes Prevention Study (DPS)Diabetes Prevention Study (DPS)

Lindström et al, Lancet Lindström et al, Lancet 2006:368;1673-792006:368;1673-79

0

10

20

30

40

50

Cum

ulat

ive

inci

denc

e of

T2D

, %

0 1 2 3 4 5 6 7 8

Follow-up time, years

Intervention

Control

Intervention ceasedIntervention ceased

88


Prevention targets the Prevention targets the population levels of population levels of most important risk most important risk factors.factors.


0 500 1000 1500 2000 2500 3000

Occu p atio n al risk facto rs fo r in ju ry

Occu p atio n al p articu lates

U n safe sex

I llic it d ru g s

Occu p atio n al carcin o g en s

L ead exp o su re

U rb an air p o llu t io n

Alco h o l

Ph ysical in act iv ity

L o w fru it an d veg etab le in take

H ig h B o d y M ass I n d ex

C h o lestero l

To b acco

B lo o d p ressu re

Developed Countries Deaths in 2000 Developed Countries Deaths in 2000 Attributable to Selected Leading Risk FactorsAttributable to Selected Leading Risk Factors

Number of deaths (000s)


Six of the Seven Top Determinants of Six of the Seven Top Determinants of Mortality in Mortality in Developed Countries Developed Countries

Relate to How We Eat, Drink and MoveRelate to How We Eat, Drink and Move

Diet and physical activity, together Diet and physical activity, together with tobacco and alcohol, are key with tobacco and alcohol, are key determinants of contemporary determinants of contemporary public healthpublic health


WHO’s NCD Strategy 2000WHO’s NCD Strategy 2000

NCD’s a priorityNCD’s a priorityPrevention keyPrevention keyIntegrated approach, targeting Integrated approach, targeting

main behavioural factors: diet, main behavioural factors: diet, physical activity and tobaccophysical activity and tobacco


Integrated Prevention - Integrated Prevention - Common Common Risk FactorsRisk Factors

TOBACCO USETOBACCO USE

UNHEALTHY DIETUNHEALTHY DIET

PHYSICAL PHYSICAL INACTIVITYINACTIVITY

ALCOHOLALCOHOL

CVD

DIABETES

CANCER

COPD

MUSCULOSCELETAL

ORAL HEALTH


Lifestyles in Key PositionLifestyles in Key Position

Individual healthIndividual healthPopulation healthPopulation health

Attention to determinants Attention to determinants of lifestyle of lifestyle changeschanges


Two Prevention StrategiesTwo Prevention Strategies

1)1) High risk strategy (individual)High risk strategy (individual)

2)2) Population strategy (public health)Population strategy (public health)



• Personal ResponsibilityPersonal Responsibility””Nobody can take better care of your Nobody can take better care of your health than yourself”health than yourself”

• Public ResponsibilityPublic Responsibility””Make the healthy choices the easy Make the healthy choices the easy ones”ones”

(Ottawa declaration)

Combing Personal and Combing Personal and Public Public ResponsibilitiesResponsibilities


PUBLIC RESPONSIBILITYPUBLIC RESPONSIBILITY

POLICY INTERVENTIONSPOLICY INTERVENTIONS


Strong Interaction BetweenStrong Interaction BetweenDifferent Levels NeededDifferent Levels Needed

GlobalGlobal

Regional EURegional EU

NationalNational

LocalLocal


Global Level: Role of WHOGlobal Level: Role of WHO

Global health policy leadership Global health policy leadership (”organization of governments”) (”organization of governments”) combinedcombined with good partnership and with good partnership and collaboration (other international collaboration (other international organizations, NGO’s, private sector)organizations, NGO’s, private sector)


Global WHO DevelopmentGlobal WHO Development

FCTC (Framework Convention on FCTC (Framework Convention on Tobacco Control) - 2003Tobacco Control) - 2003

Global strategy on diet, physical Global strategy on diet, physical activity and health - 2004activity and health - 2004


Strong Global Influences – Global Health Strong Global Influences – Global Health Actions Needed: WHO Global Strategy on Actions Needed: WHO Global Strategy on Diet, Physical Activity and Health Adopted in 2004Diet, Physical Activity and Health Adopted in 2004


WHO Global Strategy on Diet, WHO Global Strategy on Diet, Physical Activity and HealthPhysical Activity and Health

• Comprehensive roadmap for Member Comprehensive roadmap for Member States and other stakeholdersStates and other stakeholders

• Based on strong evidence and broad Based on strong evidence and broad consultationsconsultations

• Emphasizes positive actions and Emphasizes positive actions and collaborationcollaboration

• Supports Supports Member StatesMember States

• Addresses Addresses global responsesglobal responses (WHA 2004)(WHA 2004)


Limit saturated fat (<10%) and replace by Limit saturated fat (<10%) and replace by unsaturatedunsaturated

Total fat intake: 15-30%Total fat intake: 15-30%Limit salt (sodium) intake (<5 g)Limit salt (sodium) intake (<5 g)

Limit sugar intake (<10%)Limit sugar intake (<10%)Increase fruit and vegetable intake (>400 g)Increase fruit and vegetable intake (>400 g)Ensure physical activity: at least 30-60 minEnsure physical activity: at least 30-60 min

Ensure energy balanceEnsure energy balance

RECOMMENDATIONS OF WHO / FAO EXPERT RECOMMENDATIONS OF WHO / FAO EXPERT REPORT ON DIET, NUTRITION AND PREVENTION OF REPORT ON DIET, NUTRITION AND PREVENTION OF CHRONIC DISEASES (WHO / TRS s. 16; 2003)CHRONIC DISEASES (WHO / TRS s. 16; 2003)

WHO / FAO Expert ReportWHO / FAO Expert ReportRecommendationsRecommendations



27


North Karelia ProjectNorth Karelia ProjectPrinciples for Defining Principles for Defining

the Intermediate Objectivesthe Intermediate Objectives

• • Due to the chronic nature of CVD, Due to the chronic nature of CVD, the potential for the control of the problemthe potential for the control of the problemlies in lies in primary preventionprimary prevention

•• The risk factors were chosen on the basis The risk factors were chosen on the basis of of best available knowledgebest available knowledge: :

- previous studies- previous studies- collective international recommendations- collective international recommendations- epidemiological situation in North Karelia- epidemiological situation in North Karelia

•• Chosen risk factorsChosen risk factors::- smoking- smoking- elevated serum cholesterol (diet)- elevated serum cholesterol (diet)- elevated blood pressure- elevated blood pressure


From Karelia to National ActionFrom Karelia to National Action

• First province of North Karelia as First province of North Karelia as a pilot (5 years), then national action a pilot (5 years), then national action (1972–77)(1972–77)

• Continuation is North Karelia as Continuation is North Karelia as national demonstration (1977–95)national demonstration (1977–95)

• Good scientific evaluation to learn of Good scientific evaluation to learn of the experiencethe experience

• Comprehensive national actionComprehensive national action


Examples of Innovative Examples of Innovative Nutrition Activities in North KareliaNutrition Activities in North Karelia

• Lay leader programmeLay leader programme

• Berry and vegetable projectBerry and vegetable project

• Risk reduction TV programmesRisk reduction TV programmes

• Collaboration with housewives’ organizationCollaboration with housewives’ organization

• Cholesterol lowering village competitionsCholesterol lowering village competitions

• Widespread fingertip cholesterol measurementsWidespread fingertip cholesterol measurements

• Collaborative projects with industry & Collaborative projects with industry & supermarketssupermarkets

• Health fairsHealth fairs


Rapeseed OilRapeseed Oil


Fruits And Vegetables Fruits And Vegetables – Supermarkets– Supermarkets

NORDIC FOOD WEEK 19.9.2007sivu 32

•BENECOL® products available:

•Spread•Cream Cheese•Pasta•Butter Milk•Yoghurt•Yoghurt Drink•Turkey Sausage•Milk Drink•Turkey cold cuts

Functional food development: Benecol example


www.sydanmerkki.fi



Evaluation / MonitoringEvaluation / Monitoring

- North Karelia – all FinlandNorth Karelia – all Finland- Monitoring systemsMonitoring systems

• health behaviourhealth behaviour• risk factorsrisk factors• nutritionnutrition• diseases, mortalitydiseases, mortality


BIG CHANGES IN BIG CHANGES IN LIFESTYLES AND RISK LIFESTYLES AND RISK

FACTORSFACTORS


Use of Butter on Bread Use of Butter on Bread (men age 30(men age 30––59)59)

01020304050

60708090

100

1972 1977 1982 1987 1992 1997 2002

North KareliaKuopio provinceSouthwest FinlandHelsinki areaOulu provinceLapland province

Kg/m2


Use of Vegetable Oil for Cooking Use of Vegetable Oil for Cooking (men age 30(men age 30––59)59)

0

10

20

30

40

50

60

70

1972 1977 1982 1987 1992 1997 2002



Salt Intake in Finland 1977–2002Salt Intake in Finland 1977–2002g/

day

YearSources: 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


Serum Cholesterol in Men Serum Cholesterol in Men Aged 30–59 YearsAged 30–59 Years

5

5.5

6

6.5

7

7.5

1972 1977 1982 1987 1992 1997 2002

North Karelia

Kuopio

Turku/Loimaa

Helsinki/Vantaa

Oulu

Lapland

mmol/l

FINRISK Studies 1997&2002


Systolic Blood Pressure in Women Systolic Blood Pressure in Women Aged 30Aged 30––59 Years59 Years

120

130

140

150

160

1972 1977 1982 1987 1992 1997 2002


mmHg


Age-adjusted mortality rates of coronary Age-adjusted mortality rates of coronary heart disease in North Kareliaheart disease in North Karelia and the whole of and the whole of Finland among Finland among males aged males aged 3535––64 years 64 years from 1969 from 1969 to 2002.to 2002.

Mortality per Mortality per 100 000 100 000

populationpopulation100

200

300

400

500

600

700

69 72 75 78 81 84 87 90 93 96 99 2002Year

North KareliaNorth Karelia

All FinlandAll Finland

start of the North Karelia Projectstart of the North Karelia Project

- 82%- 82%

- 75%- 75%

extension of the Project nationally


Mortality Changes in North Karelia Mortality Changes in North Karelia 19701970––1995 1995 (per(per 100.000, men 35100.000, men 35––6464

years, age adjusted)years, age adjusted)

Rate inRate in Change inChange in 1970 19701970 1970––9595

All causesAll causes 1509 1509 - 49% - 49%All cardiovascularAll cardiovascular 855 855 - 68% - 68%Coronary heart diseaseCoronary heart disease 672 672 - 73% - 73%All cancersAll cancers 271 271 - 44% - 44%Lung cancersLung cancers 147 147 - 71% - 71%


Population dietary Population dietary changes explain much changes explain much

of the reduction in of the reduction in heart disease heart disease

mortality in Finland.mortality in Finland.

Vartiainen, Puska et al BMJ 1995

ObservedPredictedCholesterolBlood pressureSmoking

Observed and Predicted Declines in Observed and Predicted Declines in Coronary Mortality in Eastern Finland, Coronary Mortality in Eastern Finland, MenMen

72 9276 80 84 8874 78 82 86 90

0

-10

-20

-30

-40

-50

-60

Decline in mortality


• A comprehensive, determined and A comprehensive, determined and theory-based community program can theory-based community program can have a meaningful positive effect on riskhave a meaningful positive effect on riskfactors and life stylesfactors and life styles

• Such changes are associated with respective Such changes are associated with respective favourable changes in chronic disease rates favourable changes in chronic disease rates and and health of the populationhealth of the population

• A major national demonstration program can A major national demonstration program can be a be a strong tool for favourable national strong tool for favourable national development in development in chronic disease prevention chronic disease prevention and health promotionand health promotion

North Karelia Project

Conclusions from the North Karelia Project



DISCUSSION ON FOOD, DISCUSSION ON FOOD, NUTRITION INTERVENTIONS AND NUTRITION INTERVENTIONS AND PUBLIC HEALTH FROM THE PUBLIC HEALTH FROM THE FINNISH EXPERIENCEFINNISH EXPERIENCE


Strong Concensus for Strong Concensus for Nutrition Nutrition RecommendationsRecommendations

WHO / FAOWHO / FAO 20032003NORDIC RECOMMENDATION NORDIC RECOMMENDATION 20042004FINNISH NAT. NUTR.FINNISH NAT. NUTR. COUNCIL RECOMMENDATIONS COUNCIL RECOMMENDATIONS 2005 2005

Numerous national and expert body Numerous national and expert body recommendationsrecommendations


International StrategiesInternational Strategies

• WHO Global Strategy on Diet, Physical WHO Global Strategy on Diet, Physical Activity and Health 2004Activity and Health 2004

• Nordic Plan for Action 2006Nordic Plan for Action 2006• WHO / EU Ministerial Charter on WHO / EU Ministerial Charter on

Counteracting Obesity (Istanbul 2006)Counteracting Obesity (Istanbul 2006)• EU White Paper on Nutrition Overweight and EU White Paper on Nutrition Overweight and

Obesity (2007)Obesity (2007)


FOOD IS NOT ONLY HEALTH, FOOD IS NOT ONLY HEALTH, BUT ALSOBUT ALSO

- tastetaste- cultureculture- socialsocial

FOOD RELATES TOFOOD RELATES TO- traditiontradition- agricultureagriculture- commercial driverscommercial drivers


Healthy Food Can Taste Healthy Food Can Taste Good Good or Bador Bad

Depending onDepending on- how preparedhow preparedhow servedhow served- what people are used to what people are used to

(esp. children)(esp. children)- individual preferences individual preferences


Instead healthy food can be based on Instead healthy food can be based on different food cultures, if different food cultures, if recommendation for nutritional recommendation for nutritional composition is observedcomposition is observed

Healthy Food is not One Healthy Food is not One Type of DietType of Diet


Healthy FoodHealthy Food

- Positive choices- Can be based on local traditions- Can be domestic or international- Can be cheap or expensive


Partnerships for Public Partnerships for Public HealthHealth

Governments (national, local)Governments (national, local)Civil society (NGO’s)Civil society (NGO’s)Private sectorPrivate sector

International collaborationInternational collaboration


GovernmentsGovernments

Governments have a basic Governments have a basic responsibility for public responsibility for public healthhealth


Private SectorPrivate Sector

Health is increasingly important business Health is increasingly important business argumentargument

Product development, marketingProduct development, marketing””Health promoting business” – Health promoting business” –

sustainable businesssustainable businessSocial responsibilitySocial responsibility


PUBLICPUBLICPOLICYPOLICY

HEALTH PROGRAMMEHEALTH PROGRAMME

POPULATIONPOPULATIONPRIVATEPRIVATESECTORSECTOR


Experience in FinlandExperience in Finland• People are interested in the health messagePeople are interested in the health message• People attempt and make great changes in People attempt and make great changes in

their diettheir diet• Food industry adopts and supports the new Food industry adopts and supports the new

trends; health is a major driver for product trends; health is a major driver for product development and marketingdevelopment and marketing

• Health claims, nutrition labelling and Health claims, nutrition labelling and information importantinformation important


Economic Drivers for Chronic Economic Drivers for Chronic Disease Disease PreventionPrevention

1)1) Availability and health of the shrinking Availability and health of the shrinking working age populationworking age population

2)2) Health and functional capacity of the Health and functional capacity of the increasing elderly populationincreasing elderly population


Finland Has ShownFinland 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 calls for simple changes in some lifestyles

(individual, family, community, national and global level action) Influencing national diets and lifestyles is a key issue Many results of prevention occur surprisingly quickly

(CVD, diabetes) and also at relatively late age Comprehensive action, broad collaboration with dedicated

leadership and strong government policy support


NORDIC FOOD WEEK, NORDIC FOOD WEEK, St. Petersburg 19.9.2007 St. Petersburg 19.9.2007

Health & Medicine

North karelia