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Lessons from Finland

Phenomenal Lessons from North Karelia Project in Finland 
  • In the late 1960s, CAD mortalityamong Finnish men was the highest in the world. In 1972, the North Karelia Project, a comprehensive community-based intervention program was launched to reduce the burden of CAD.1 The program has been gradually implemented nationwide.  Population risk factor surveys have been carried out at 5-year intervals. The target population has been persons aged 25–74 years,except in the first two surveys where the sample was drawn froma population aged 30–59 years.
  • Between 1970 and 2002, the age-standardized death rates (per 100,000)  for heart disease decreased by 67% (697 to 231) in men and 70% (192 to 58) in women.2 The annual average decline in CAD mortality rate was  5% among men and 6% among women during 1991-2001.3 The latest update of the study (2010) reported an 80% decline in CAD mortality over the 35 years between 1972 and 2007.4
  • Improved treatments explained approximately 23% of the mortality reduction, and improved risk factors explained some 53-72% of the reduction. These findings highlight the value of a comprehensive strategy that promotes primary prevention programs and actively supports secondary prevention.5
  • A remarkable decline in serum cholesterol levels wasobserved─ 21% in men and 23% in women. The average decline was 59 mg/dl.4, 5 The diastolic blood pressure declined by an average of 9 mmHg. Prevalence of smoking decreased in men but increased throughout the survey years until 2002 (butdid not increase since then). Women however had a greater decrease in blood pressure and cholesterol levels.
  • On balance, the smoking decreased by 15 points. Body mass index (BMI)has continuously increased among men. Among women, BMI decreaseduntil 1982, but since then an increasing trend has been observed.The  current prevalence is 21% for obesity (both genders), 30% for smoking in men (from 52% to 30%), and 21% in women.4
  • The 80% decline in CAD mortality in Finland  mainly reflects a great reduction of the risk factor levels;Risk factor changes explained a 60% of this reduction in CAD mortality.4, 5 The decile was greater among those who <45 years , who increased the average age of a first heart attack by 20 years (from 50 to 70 years).6
  • Finland has one of the lowest rates of coronary angioplasty and bypass surgeries in Europe and did not make any significant contribution.
  • In addition to the benefits on CAD mortality and quality of life, the program benefited other chronic diseases such as stroke, diabetes, and cancer.4
  • Since the population reduction in cholesterol was achieved primarily through the reduction in the intake of saturated fat and increase in unsaturated fats, a dramatic reduction in cholesterol levels was observed in the second and third generations of Finns with a similar decline in smoking rates.4, 6

   North Karelia project

  • The main aim of the project was to change population diets, especially with respect to the quality of fat: to reduce saturated and increase unsaturated fat intake. In addition, emphasis was placed on increased vegetable intake and salt reduction.1 The various initiatives the project successfully undertook is given in the Table 134 A.
  • This comprehensive action in Finland has involved health education programs, preventive measures in health services, actions at schools, broad collaboration with non-governmental and private sector organizations, government policies, population-based monitoring and evaluation, and international collaboration.1

 

Table 134 A.  North Karelia Project Health Initiatives that

Reduced CAD mortality by 80% in 35 years

1 Engaging agriculture, supermarkets and the food industry to support environmental change e.g. supporting dairy farmers to switch to healthier berry production
2 Developing low fat dairy and filtered coffee products
3 Developing healthy margarines with phytosterols capable of lowering blood cholesterol
4 Educating the public and health professionals (e.g. through innovative media campaigns) to encourage change and drive demand for healthier products such as low fat milk
5 Engaging the local house-wives organization to train and educate mothers in healthy cooking
6 Collaboration with national authorities, and influencing national policy
  • The combined efforts of all stakeholders have greatly helped people to reduce the intake of saturated fat and to replace this with unsaturated fat. Major dietary changes resulted in marked reductions in saturated fat exemplified by reduction in the use of butter on bread from 90% to <5% with a remarkable reduction in blood cholesterol levels.
  • It has led to an 80% reduction in annual cardiovascular disease (CVD) mortality rates among the working age population, to a major increase in life expectancy and to major improvements in functional capacity and health. Studies have shown that the reduction in blood cholesterol levels, explained by the target dietary changes, have had the greatest impact on these very favorable health changes.
  • A major factor leading to the success of the North Karelia Program was community organization. Thus, effective strategies in low- and middle-income countries may involve not only major government initiatives in population based prevention but also strong community efforts and collaboration to foster environments that promote and support cardiovascular health.
  • The Finnish experience shows both the feasibility and great potential of CVD prevention through general dietary changes at the community level in a resource poor setting.7

Sources

1. Puska P. Fat and heart disease: yes we can make a change–the case of North Karelia (Finland). Ann Nutr Metab. 2009;54 Suppl 1:33-38.

2. www.heartstats.org. CHD Statistics. mortality. 2008. Accessed May 1,2010.

3. Pietinen P, Vartiainen E, Seppanen R, Aro A, Puska P. Changes in diet in Finland from 1972 to 1992: impact on coronary heart disease risk. Prev Med. May-Jun 1996;25(3):243-250.

4. Vartiainen E, Laatikainen T, Peltonen M, et al. Thirty-five-year trends in cardiovascular risk factors in Finland. Int J Epidemiol. Apr 2010;39(2):504-518.

5. Laatikainen T, Critchley J, Vartiainen E, Salomaa V, Ketonen M, Capewell S. Explaining the decline in coronary heart disease mortality in Finland between 1982 and 1997. Am J Epidemiol. Oct 15 2005;162(8):764-773.

6. Pyorala K, Palomaki P, Miettinen H, Mustaniemi H, Salomaa V, Valkonen T. Decline in coronary heart disease mortality in Finland: Effect of age and gender distribution on the disease. Am. J. Ger. Cardiol. 1994;May/June:20-32.

7. Enas EA, Jacob S. Decline of CAD in developed countries: Lessons for India. In: Sethi K, ed. Coronary Artery Disease in Indians – A Global Perspective. Mumbai: Cardiological Society of India; 1998:98 -113.

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