Results of the North Karelia Project and national NCD prevention Erkki Vartiainen, MD, Professor, Assistant Director General 28/03/2011 Erkki Vartiainen 1
2
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 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
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
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
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
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
Hypertension register Computer based Hypertension clinic Nurses in a key position Invitation letter once a year
NSO s role Heart Association Martta (house wife s) association
Setting strategy Schools Work site Media Family Health centers/hospitals Villages
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 1975-1982 Evaluation in 1982: 399 (50%) still active
Discussions with target groups Target group Very often (%) Occasionally(%) Family 43 41 Neighbours 18 60 Work 16 31 Relatives 20 48 Friends 18 46 NGO meetings 13 28 Shopkeepers 8 27 Media 0 15
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 250 000 at least 4 sessions 30 000 attempt to quit 20 000 quit 10 000 remained non-smokers
Berry program From dairy industry to berry production Helping in marketing and product development Funding from ministry
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
Village competition to lower cholesterol 1991 7 villages, population 105-210 1997 16 villages, population 85-420 Village committees organized 2 months competition Baseline and follow-up cholesterol measurement Best village win 2000
Cholesterol changes in 1991 competition Village Baseline % Change 1 5.9-10.8 2 5.8-9.2 3 5.9-8.9 4 5.9-6.8 5 6.0-4.0 6 5.7-2.3 7 5.7 +1.4 Mean 5.8 5.8
Cholesterol change in 1997 competition Baseline End Change Change% N 6.19 5.59-0.60-9.0 16
Change (%) in cholesterol by number of dietary changes 0-2,-1 0 1 2 3 5 10 15 20 25
Change in cholesterol value by village activity 5 0-5 0 2 4 6 8 10-10 -15-20
% Percentage of weekly smokers (Baseline smokers excluded) Program effect 1 8th OR = 0.47 (0.30-0.71) 51% 9th OR = 0.68 (0.51-0.89) 28% 25 20 15 10 5 4,4 9 14,3 19,9 Experimental Control 0 8th 9th The OR for weekly smoking for experimental school compared to control school pupils
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
Serum cholesterol in women 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
Serum cholesterol distribution in North Karelia in 1972 and 2007
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
1982, 1992, 1997, 2002, 2007 FINMONICA/FINRISK surveys Age and sex-stratified random sample, 25-64-years, in 3-5 study areas Diet subsample 3000-4000 Response rates, 60-70% 3-day food record, 1982, 1992 24 h recall, 1997 48 h recall, 2002 and 2007
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
mmol/l -1.0-0.8-0.6-0.4-0.2 0.0 Estimated effects on serum cholesterol Pufa Dietary chol Sfa Pufa+D-Chol+Sfa Pufa+D-Chol+Sfa+Trans-FA Observed S-Chol 1982 1992 2002 2007 Year
Estimated effect of statins on population cholesterol 7 6 5 4 3 2 4% 1987 2007 Estimate 2007 1 0 25-34 34-44 45-54 55-64
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 4,47 4 1982 1987 1992 1997 2002 2007
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
Systolic blood pressure in women aged 30-59 years 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
Diastolic blood pressure in men aged 30-59 years mmhg 95 90 85 North Karelia Kuopio province Southwest Finland Helsinki area Oulu province Lapland province 80 75 1972 1977 1982 1987 1992 1997 2002 2007
Diastolic blood pressure in women aged 30-59 years mmhg 95 90 85 North Karelia Kuopio province Southwest Finland Helsinki area Oulu province Lapland province 80 75 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
Body mass index in women aged 30-59 years 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
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.
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
Smoking in men aged 30-59 years % 60 50 40 30 North Karelia Kuopio province Southwest Finland Helsinki area Oulu province Lapland province 20 10 0 1972 1977 1982 1987 1992 1997 2002 2007
Smoking in women aged 30-59 years % 60 50 40 30 20 10 North Karelia Kuopio province Southwest Finland Helsinki area Oulu province Lapland province 0 1972 1977 1982 1987 1992 1997 2002 2007
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
Thank you!
% 35 Projected impact of risk factor changes in Australia All 30 25 20 15 10 Chol 10% HR chol 4.5 Combination BP 5% HR 140 Combination No smoking 5 0 Vartainen et al MJA 2011;194:10-15 68
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
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
North Karelia Project MEDICAL KNOWLEDGE SOSIAL & BEHAVIORAL THEORY COMMUNITY PROGRAM HARD PRACTICAL WORK
Chow et Int J Epidemiol 2009;38:1580
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
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
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
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