International model for prevention of chronic disease: Finland experience Erkki Vartiainen, MD, Professor, Assistant Director General 06/12/2011 Erkki Vartiainen 1
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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
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?
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
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
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
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
II. BEHAVIOUR MODIFICATION 6. COMMUNITY ORGANIZATION 4. SOCIAL SUPPORT 5. ENVIRONMENTAL SUPPORT 3. PRACTICAL SKILLS 2. PERSUASION 1. KNOWLEDGE World Health Organization (Puska and McAlister)
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
Erkki Vartiainen
Serum cholesterol in men aged 30-59 years mmol/l 7,5 7 6,5 North Karelia Kuopio province Southwest Finland Helsinki area Oulu province Lapland province 6 5,5 5 1972 1977 1982 1987 1992 1997 2002 2007
Cholesterol distribution in North Karelia in 1972 and 2007, men
Use of butter for cooking % 80 70 60 50 40 30 20 10 0 1972 1977 1982 1987 1992 1997 2002 2007 North Karelia Kuopio province Southwest Finland Helsinki area Oulu province Lapland province
Use of vegetable oil for cooking (men age 30-59) 70 60 50 40 North Karelia Kuopio province Southwest Finland Helsinki area Oulu province Lapland province 30 20 10 0 1972 1977 1982 1987 1992 1997 2002 2007
Use of butter on bread (men age 30-59) % 100 90 80 70 60 50 40 30 20 10 0 1972 1977 1982 1987 1992 1997 2002 2007 North Karelia Kuopio province Southwest Finland Helsinki area Oulu province Lapland province
Fat intake 40 Recommendations 30 Total fat (~ 30 EN%) EN% 20 10 SAFA (~10 EN%) MUFA (10-15 EN%) 0 1982 1987 1992 1997 2002 2007 Year PUFA (5-10 EN%)
mmol/l -1.0-0.8-0.6-0.4-0.2 0.0 Estimated effects on serum cholesterol Medication effect Dietary effect Medication+dietary effect Observed S-Chol 1982 1992 2002 2007 Year
Systolic blood pressure in men aged 30-59 mmhg 160 150 140 North Karelia Kuopio province Southwest Finland Helsinki area Oulu province Lapland province 130 120 1972 1977 1982 1987 1992 1997 2002 2007
Salt intake in Finland 1977-2007 g/day 18 16 14 12 Calculated, men Calculated, women 24 hour urine, men 10 8 6 4 2 0 1977 1979 1981 1982 1987 1991 1992 1994 1997 1998 2002 2007 24 hour urine, women Linear (24 hour urine, men) Linear (24 hour urine, women) Linear (Calculated, men) Linear (Calculated, women)
Body mass index in men aged 30-59 Kg/m 2 30 29 28 North Karelia Kuopio province Southwest Finland Helsinki area Oulu province Lapland province 27 26 25 1972 1977 1982 1987 1992 1997 2002 2007
BMI by education, women 25-64 years kg/m 2 28 27 26 Highest Medium Lowest 25 1997 2002 2007
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
Cumulative incidence of T2D, % DPS-F study Diabetes by treatment group during the total follow-up period 50 40 Log-rank test: p=0.0001 Hazard ratio=0.57 (95% CI 0.43-0.76) Control 30 20 10 Intervention 0 Intervention ceased 0 1 2 3 4 5 6 7 8 Follow-up time, years Lindström et. al. Lancet 2006:368;1673-79
Diabetes incidence per 100 person years Finnish DPS-F study Diabetes incidence rate by success score (number of intervention goals achieved) 10 8 6 8 7 Test of trend: p<0.001 5 5 4 3 2 0 0 1 2 3 4 5 Number of goals achieved at year 3 0 Lindström et. al. Lancet 2006
Background Disturbances in glucose metabolism in Finns aged 45-74 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;61:163-170
FIN-D2D high-risk subjects 10,200 high risk persons included in interventions in primary and occupational health care during 2004-2007. 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.
Figure 2. Male and female ever-regular smoking by birth cohort Figure 1. Daily smoking prevalence 1960 2005 % 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 50 40 30 Men 90 80 70 60 50 Men 20 10 0 Women 40 30 20 10 0 Women Year 19-34 35-49 50-64 25-49 25-49 19-34 35-49 50-64 25-49 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
Age-adjusted mortality rates of coronary heart disease in North Karelia and the whole of Finland among males aged 35 64 years from 1969 to 2006. 700 600 500 400 start of the North Karelia Project extension of the Project nationally North Karelia Mortality per 100 000 population Age-standadized to European population 300 200 100 All Finland 69 72 75 78 81 84 87 90 93 96 99 2002 2005 Year
North Karelia Project Prevention of CVD Do the risk factor changes explain the CVD mortality changes?
Observed and predicted decline in CHD mortality in men % 0-10 -20-30 -40-50 -60-70 -80-90 1972 1977 1982 1987 1992 1997 2002 2007 Year Observed All risk factors Cholesterol Diastolic BP Smoking
CHD mortality fall in Finland 1982 1997 0-100 -200-300 -400 373 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% 1982 1997 T Laatikainen et al Am J Epid 2005
Subjective health: percent stating their health as good or very good (men) % 70 60 50 North Karelia Kuopio province Southwest Finland Helsinki area 40 30 1972 1977 1982 1987 1992 1997 2002 Year
Collaboration with WHO Collaborating center in NCD prevention and monitoring Participation in WHO and WHO/EURO NCD strategy development and implementation NCD international annual NCD seminar in Finland Lectures in other WHO seminars CINDI program
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
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
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
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
Major elements of successful National Preventive Program 2 National demonstration programme(s), focal point(s) Policy decisions, intersectoral collaboration, legislation Monitoring system International collaboration
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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