Results of the North Karelia Project and national NCD prevention
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1 Results of the North Karelia Project and national NCD prevention Erkki Vartiainen, MD, Professor, Assistant Director General 28/03/2011 Erkki Vartiainen 1
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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: Improved health MAIN OBJECTIVES: Prevention of chronic diseases & promotion of health INTERMEDIATE OBJECTIVES: Risk factors, life-styles and treatment PRACTICAL OBJECTIVES: Intervention programme Medical / Epidemiological framework: - earlier research - local prevalence Social / Behavioural framework: - theory - community analysis
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 5 % 70 % 25 % 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
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11 North Karelia Project Theoretical principles of the interventions Medical framework: Primary prevention Main targets: smoking, diet, cholesterol, blood pressure Population 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. 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 Smoking control programmes Voluntary restrictions of smoking in public places Mass media Voluntary restrictions in advertising Use of opinion leaders Training of health care personnel Cessation services in health centres
15 Hypertension register Computer based Hypertension clinic Nurses in a key position Invitation letter once a year
16 NSO s role Heart Association Martta (house wife s) association
17 Setting strategy Schools Work site Media Family Health centers/hospitals Villages
18 Use of lay opinion leaders to promote health innovations in community Innovation-diffusion theory Training seminars in municipalities Discuss health issues in normal life 805 persons participated Recruiting by local people and Heart Association Evaluation in 1982: 399 (50%) still active
19 Discussions with target groups Target group Very often (%) Occasionally(%) Family Neighbours Work Relatives Friends NGO meetings Shopkeepers 8 27 Media 0 15
20 A comprehensive television smoking cessation programme in Finland Voluntary smokers in TV studio tried to stop smoking 6 sessions + 2 follow-up sessions Intensified filed activity in North Karelia at least 4 sessions attempt to quit quit remained non-smokers
21 Berry program From dairy industry to berry production Helping in marketing and product development Funding from ministry
22 Smoking control programmes Work side programmes School programmes TV programmes Radio programmes Quit and Win Competition Smoke Free Class Competition Quit and Win-Do Not Start and Win for Young People
23 Village competition to lower cholesterol villages, population villages, population Village committees organized 2 months competition Baseline and follow-up cholesterol measurement Best village win 2000
24 Cholesterol changes in 1991 competition Village Baseline % Change Mean
25 Cholesterol change in 1997 competition Baseline End Change Change% N
26 Change (%) in cholesterol by number of dietary changes 0-2,
27 Change in cholesterol value by village activity
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30 % Percentage of weekly smokers (Baseline smokers excluded) Program effect 1 8th OR = 0.47 ( ) 51% 9th OR = 0.68 ( ) 28% ,4 9 14,3 19,9 Experimental Control 0 8th 9th The OR for weekly smoking for experimental school compared to control school pupils
31 Erkki Vartiainen
32 Serum cholesterol in men aged years mmol/l 7,5 7 6,5 North Karelia Kuopio province Southwest Finland Helsinki area Oulu province Lapland province 6 5,
33 Serum cholesterol in women aged years mmol/l 7,5 7 6,5 North Karelia Kuopio province Southwest Finland Helsinki area Oulu province Lapland province 6 5,
34 Serum cholesterol distribution in North Karelia in 1972 and 2007
35 Use of butter for cooking % North Karelia Kuopio province Southwest Finland Helsinki area Oulu province Lapland province
36 Use of vegetable oil for cooking (men age 30-59) North Karelia Kuopio province Southwest Finland Helsinki area Oulu province Lapland province
37 Use of butter on bread (men age 30-59) % North Karelia Kuopio province Southwest Finland Helsinki area Oulu province Lapland province
38 1982, 1992, 1997, 2002, 2007 FINMONICA/FINRISK surveys Age and sex-stratified random sample, years, in 3-5 study areas Diet subsample Response rates, 60-70% 3-day food record, 1982, h recall, h recall, 2002 and 2007
39 Fat intake 40 Recommendations 30 Total fat (~ 30 EN%) EN% SAFA (~10 EN%) MUFA (10-15 EN%) Year PUFA (5-10 EN%)
40 mmol/l Estimated effects on serum cholesterol Medication effect Dietary effect Medication+dietary effect Observed S-Chol Year
41 mmol/l Estimated effects on serum cholesterol Pufa Dietary chol Sfa Pufa+D-Chol+Sfa Pufa+D-Chol+Sfa+Trans-FA Observed S-Chol Year
42 Estimated effect of statins on population cholesterol % Estimate
43 Serum cholesterol level by myocardial infarction and statins 7 6,78 6,75 6,5 6 5,5 5 6,3 6,2 5,96 5,91 5,82 5,7 5,66 5,66 5,6 5,52 5,54 5,37 5,07 4,92 5,37 4,99 MI patients NO MI MI and statins MI no statins 4,5 4,58 4,
44 Systolic blood pressure in men aged mmhg North Karelia Kuopio province Southwest Finland Helsinki area Oulu province Lapland province
45 Systolic blood pressure in women aged years mmhg North Karelia Kuopio province Southwest Finland Helsinki area Oulu province Lapland province
46 Diastolic blood pressure in men aged years mmhg North Karelia Kuopio province Southwest Finland Helsinki area Oulu province Lapland province
47 Diastolic blood pressure in women aged years mmhg North Karelia Kuopio province Southwest Finland Helsinki area Oulu province Lapland province
48 Salt intake in Finland g/day Calculated, men Calculated, women 24 hour urine, men hour urine, women Linear (24 hour urine, men) Linear (24 hour urine, women) Linear (Calculated, men) Linear (Calculated, women)
49 Body mass index in men aged Kg/m North Karelia Kuopio province Southwest Finland Helsinki area Oulu province Lapland province
50 Body mass index in women aged years Kg/m North Karelia Kuopio province Southwest Finland Helsinki area Oulu province Lapland province
51 BMI by education, women years kg/m Highest Medium Lowest
52 Cumulative incidence of T2D, % DPS-F study Diabetes by treatment group during the total follow-up period Log-rank test: p= Hazard ratio=0.57 (95% CI ) Control Intervention 0 Intervention ceased Follow-up time, years Lindström et. al. Lancet 2006:368;
53 Diabetes incidence per 100 person years Finnish DPS-F study Diabetes incidence rate by success score (number of intervention goals achieved) Test of trend: p< Number of goals achieved at year 3 0 Lindström et. al. Lancet 2006
54 Background Disturbances in glucose metabolism in Finns aged y. FIN-D2D survey 2004 (n=2896) Men Women Diagnosed type 2 diabetes 7.4% 4.3% } 15.7% Screen-detected type 2 diabetes 8.3% 6.9% Impaired glucose tolerance 14.7% 15.9% Impaired fasting glucose 9.3% 4.8% } 11.2% Total*: 41.8% 33.2% * Age-adjusted Suom Lääkäril 2006;61:
55 FIN-D2D high-risk subjects 10,200 high risk persons included in interventions in primary and occupational health care during Additional 10,000 persons with risk score 7-14 have received written information. A total of >20,000 have contacted primary or occupational health care system due to programme.
56 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
57 Smoking in men aged years % North Karelia Kuopio province Southwest Finland Helsinki area Oulu province Lapland province
58 Smoking in women aged years % North Karelia Kuopio province Southwest Finland Helsinki area Oulu province Lapland province
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60 Figure 2. Male and female ever-regular smoking by birth cohort Figure 1. Daily smoking prevalence % 60 WW I generation/ Early independence generation % 100 Depression generation Post WW II Baby-boomer generation Early 1960 s generation entering into typical smoking initiation age when TCA 1976 was enforced Men Men Women Women Year 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
61 Age-adjusted mortality rates of coronary heart disease in North Karelia and the whole of Finland among males aged years from 1969 to start of the North Karelia Project extension of the Project nationally North Karelia Mortality per population Age-standadized to European population All Finland Year
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64 North Karelia Project Prevention of CVD Do the risk factor changes explain the CVD mortality changes?
65 Observed and predicted decline in CHD mortality in men % Year Observed All risk factors Cholesterol Diastolic BP Smoking
66 CHD mortality fall in Finland fewer deaths Risk Factors -71% Cholesterol - 53% Smoking - 11% Blood pressure - 7% Treatments -24% AMI treatments - 4% Secondary prevention - 8% Heart failure - 2% Angina: CABG & PTCA - 8% Angina: Aspirin etc - 2% Other Factors -5% T Laatikainen et al Am J Epid 2005
67 Thank you!
68 % 35 Projected impact of risk factor changes in Australia All Chol 10% HR chol 4.5 Combination BP 5% HR 140 Combination No smoking 5 0 Vartainen et al MJA 2011;194:
69 Subjective health: percent stating their health as good or very good (men) % North Karelia Kuopio province Southwest Finland Helsinki area Year
70 North Karelia Project From pilot/demonstration program to national action National health program Medical knowledge NATIONAL DEMONSTRATION PROGRAM Public need for change Visible experiences, results National policy NATIONAL ACTION Diffusion
71 North Karelia Project MEDICAL KNOWLEDGE SOSIAL & BEHAVIORAL THEORY COMMUNITY PROGRAM HARD PRACTICAL WORK
72 Chow et Int J Epidemiol 2009;38:1580
73 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
74 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
75 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
76 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
77 Major elements of successful National Preventive Program 2 National demonstration programme(s), focal point(s) Policy decisions, intersectoral collaboration, legislation Monitoring system International collaboration
78 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
79 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
80 PROMOTING CARDIOVASCULAR HEALTH AND PREVENTING CARDIOVASCULAR DISEASES Health Promotion FINNISH HEART PLAN How to reduce the number of cardiovascular 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 Prevention Population strategy Cardiovascular diseases and life style Physical activity Nutrition Heart Symbol Canteen catering Weight control Non-Smoking disease morbidity and mortality by half 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 STRAGEGIES OF EARLY DIAGNOSTICS AND TREATMENT - 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 REHABILITATION AND SECUNDARY PREVENTION - 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
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