Ncd2014 cvd prevention in finland 2013 e_vartiainen

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Ncd2014 cvd prevention in finland 2013 e_vartiainen

  1. 1. Form North Karelia project to National NCD prevention Erkki Vartiainen, MD, Professor, Assistant Director General 13/03/2014 Erkki Vartiainen 1
  2. 2. 2
  3. 3. 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
  4. 4. 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?
  5. 5. 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
  6. 6. Hierarchy of objectives North Karelia Project GENERAL GOAL: Improved health MAIN OBJECTIVES: Prevention of chronic diseases & promotion of health Medical / Epidemiological framework: - earlier research - local prevalence INTERMEDIATE OBJECTIVES: Risk factors, life-styles and treatment PRACTICAL OBJECTIVES: Intervention programme Social / Behavioural framework: - theory - community analysis
  7. 7. 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
  8. 8. Theoretical presentation of the difference between individual risk and the proportional attributable risk 5 % 25 %70 % 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
  9. 9. 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
  10. 10. World Health Organization II. BEHAVIOUR MODIFICATION 6. COMMUNITY ORGANIZATION 5. ENVIRONMENTAL SUPPORT 4. SOCIAL SUPPORT 3. PRACTICAL SKILLS 2. PERSUASION 1. KNOWLEDGE (Puska and McAlister)
  11. 11. 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
  12. 12. 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 North Karelia Project
  13. 13. Erkki Vartiainen
  14. 14. Serum cholesterol (men30-59) mmol/L 5 5,5 6 6,5 7 7,5 1972 1977 1982 1987 1992 1997 2002 2007 2012 North Karelia Kuopio province Southwest Finland Helsinki area Oulu province
  15. 15. Serum cholesterol (women 30-59) mmol/L 5 5,5 6 6,5 7 7,5 1972 1977 1982 1987 1992 1997 2002 2007 2012 North Karelia Kuopio province Southwest Finland Helsinki area Oulu province
  16. 16. Cholesterol distribution in North Karelia in 1972 and 2007, men
  17. 17. Use of butter for cooking (men 30-59) 0 10 20 30 40 50 60 70 80 1972 1977 1982 1987 1992 1997 2002 2007 2012 North Karelia Kuopio province Southwest Finland Helsinki area Oulu province %
  18. 18. Use of vegetable oil for cooking (men age 30-59) 0 10 20 30 40 50 60 70 1972 1977 1982 1987 1992 1997 2002 2007 2012 North Karelia Kuopio province Southwest Finland Helsinki area Oulu province
  19. 19. Use of butter on bread (men age 30-59) 0 10 20 30 40 50 60 70 80 90 100 1972 1977 1982 1987 1992 1997 2002 2007 2012 North Karelia Kuopio province Southwest Finland Helsinki area Oulu province %
  20. 20. Spread used on bread (men 30-59) 0 10 20 30 40 50 60 70 80 90 1972 1977 1982 1987 1992 1997 2002 2007 2012 Margarine Butter-oil Butter 13/03/2014 Erkki Vartiainen 22
  21. 21. Spread used on bread (women 30-59) 0 10 20 30 40 50 60 70 80 90 1972 1977 1982 1987 1992 1997 2002 2007 2012 Margarine Butter-oil Butter 13/03/2014 Erkki Vartiainen 23
  22. 22. Dietary cholesterol intake (mg) 525 410 340 275 256 296 374 305 235 188 176 210 0 100 200 300 400 500 600 1982 1992 1997 2002 2007 2012 Men Women 13/03/2014 Erkki Vartiainen 24
  23. 23. 1982, 1992, 1997, 2002, 2007, 2012 • 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, 2007 and 2012
  24. 24. Fat intake (men 25-64) 0 10 20 30 40 1982 1992 1997 2002 2007 2012 Total fat (25-35 EN%) SAFA (~10 EN%) MUFA (10-15 EN%) PUFA (5-10 EN%) EN% Recommendations Year
  25. 25. Fat intake (women 25-64) 0 10 20 30 40 1982 1992 1997 2002 2007 2012 Total fat (25-35 EN%) SAFA (~10 EN%) MUFA (10-15 EN%) PUFA (5-10 EN%) EN% Recommendations Year
  26. 26. Estimated effects on serum cholesterol Year mmol/l 1982 1992 2002 2007 -1.0-0.8-0.6-0.4-0.20.0 Medication effect Dietary effect Medication+dietary effect Observed S-Chol
  27. 27. BMI by education, women 25-64 years 25 26 27 28 1997 2002 2007 Highest Medium Lowest kg/m2
  28. 28. Systolic blood pressure (men 30-59) 120 130 140 150 160 1972 1977 1982 1987 1992 1997 2002 2007 2012 North Karelia Kuopio province Southwest Finland Helsinki area Oulu province mmHg
  29. 29. Systolic blood pressure (women 30-59) 120 130 140 150 160 1972 1977 1982 1987 1992 1997 2002 2007 2012 North Karelia Kuopio province Southwest Finland Helsinki area Oulu province mmHg
  30. 30. Diastolic blood pressure (men 30-59) 70 80 90 100 1972 1977 1982 1987 1992 1997 2002 2007 2012 North Karelia Kuopio province Southwest Finland Helsinki area Oulu province mmHg
  31. 31. Diastolic blood pressure (women 30-59) 70 80 90 100 1972 1977 1982 1987 1992 1997 2002 2007 2012 North Karelia Kuopio province Southwest Finland Helsinki area Oulu province mmHg
  32. 32. Salt intake in Finland 1977-2007 0 2 4 6 8 10 12 14 16 18 1977 1979 1981 1982 1987 1991 1992 1994 1997 1998 2002 2007 Calculated, men Calculated, women 24 hour urine, men 24 hour urine, women Linear (24 hour urine, men) Linear (24 hour urine, women) Linear (Calculated, men) Linear (Calculated, women) g/day
  33. 33. Salt intake (grams) in dietary survey 12 10,5 9,9 8,4 8,9 8 7,2 6,8 6,1 6,5 0 2 4 6 8 10 12 14 1992 1997 2002 2007 2012 Men Women 13/03/2014 Erkki Vartiainen 35
  34. 34. Examples of intersectoral work 1. Development of Finnish Rapeseed oil Fen:y= -0.16x+ 362 Gen:y= -0.16x+ 358 41 42 42 43 43 44 44 45 45 1970 1975 1980 1985 1990 1995 2000 2005 2010 Year g/kg Fen Gen Change in fat content of Finnish cow milk
  35. 35. Examples of intersectoral work 2 Biscuit example: • Leading Finnish biscuit manufacturer (LU Finland Ltd) has removed some 80.000 kg of SAFA by changing the fats used • All trans fats removed and major transfer to rapeseed oil Meat product example: HK (Leading Finnish meat company) since 2007 annually: • 60.000 kg less salt • 100.000 kg less saturated fat in their products (will be increased to 500 000 kg due to change in pig feeding) 1 9 7 5 1 9 8 0 1 9 8 5 1 9 9 0 1 9 9 5 Y E A R 1 . 6 1 . 8 2 . 0 2 . 2 2 . 4 Saltconcentration(%) S a l t l e v e l i n F i n The average salt content of HK products
  36. 36. • Goal: to help consumers make better choices regarding the quality and quantity of fat and the quantity of sodium • ~ 900 products Find a symbol of your life Examples of intersectoral work 3.
  37. 37. Body mass index (men 30-59) 25 26 27 28 29 30 1972 1977 1982 1987 1992 1997 2002 2007 2012 North Karelia Kuopio province Southwest Finland Helsinki area Oulu province Kg/m2
  38. 38. 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
  39. 39. Smoking (men 30-59) 0 10 20 30 40 50 60 1972 1977 1982 1987 1992 1997 2002 2007 2012 North Karelia Kuopio province Southwest Finland Helsinki area Oulu province %
  40. 40. Smoking (women 30-59) 0 5 10 15 20 25 30 35 1972 1977 1982 1987 1992 1997 2002 2007 2012 North Karelia Kuopio province Southwest Finland Helsinki area Oulu province %
  41. 41. Figure 2. Male and female ever-regular smoking by birth cohort Figure 1. Daily smoking prevalence 1960–2005 Women Men % 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 Year 0 10 20 30 40 50 60 Women Men % Early 1960’s generation entering into typical smoking initiation age when TCA 1976 was enforced WW I generation/ Early independence generation Depression generation Post WW II Baby-boomer generation 0 10 20 30 40 50 60 70 80 90 100 19-34 35-49 50-64 25-49 25-49 19-34 35-49 50-64 25-49 25-49
  42. 42. DPS-F study Diabetes by treatment group during the total follow-up period Lindström et. al. Lancet 2006:368;1673-79 Log-rank test: p=0.0001 Hazard ratio=0.57 (95% CI 0.43-0.76) 0 10 20 30 40 50 CumulativeincidenceofT2D,% 0 1 2 3 4 5 6 7 8 Follow-up time, years Intervention Control Intervention ceased
  43. 43. 8 7 5 5 3 0 0 2 4 6 8 10 0 1 2 3 4 5 Number of goals achieved at year 3 Diabetesincidenceper100personyears Diabetes incidence rate by success score (number of intervention goals achieved) Lindström et. al. Lancet 2006 Test of trend: p<0.001 Finnish DPS-F study
  44. 44. Men Women • Diagnosed type 2 diabetes 7.4% 4.3% • Screen-detected type 2 diabetes 8.3% 6.9% • Impaired glucose tolerance 14.7% 15.9% • Impaired fasting glucose 9.3% 4.8% Disturbances in glucose metabolism in Finns aged 45-74 y. FIN-D2D survey 2004 (n=2896) Suom Lääkäril 2006;61:163-170* Age-adjusted Background }15.7% • Total*: 41.8% 33.2% }11.2%
  45. 45. 13/03/2014 Erkki Vartiainen 47 Cuba obesity and diabetes
  46. 46. 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.
  47. 47. Predicting changes in lifestyle and clinical outcomes in preventing diabetes: the Greater Green Triangle Diabetes Prevention Project
  48. 48. Predicting changes in lifestyle and clinical outcomes in preventing diabetes: the Greater Green Triangle Diabetes Prevention Project
  49. 49. 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. Mortality per 100 000 population Age-standadized to European population 100 200 300 400 500 600 700 69 72 75 78 81 84 87 90 93 96 99 2002 2005 start of the North Karelia Project extension of the Project nationally North Karelia All Finland Year
  50. 50. Prevention of CVD Do the risk factor changes explain the CVD mortality changes? North Karelia Project
  51. 51. Observed and predicted decline in CHD mortality in men -90 -80 -70 -60 -50 -40 -30 -20 -10 0 1972 1977 1982 1987 1992 1997 2002 2007 Year % Observed All risk factors Cholesterol Diastolic BP Smoking
  52. 52. CHD mortality fall in Finland 1982 – 1997 -400 -300 -200 -100 0 373 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% 19971982 T Laatikainen et al Am J Epid 2005
  53. 53. Subjective health: percent stating their health as good or very good (men 30-59) 30 40 50 60 70 1972 1977 1982 1987 1992 1997 2002 2007 2012 % North Karelia Kuopio province Southwest Finland Helsinki area Oulu province
  54. 54. Subjective health: percent stating their health as good or very good (women 30-59) 30 40 50 60 70 1972 1977 1982 1987 1992 1997 2002 2007 2012 % North Karelia Kuopio province Southwest Finland Helsinki area Oulu province
  55. 55. Thank you !
  56. 56. From pilot/demonstration program to national action North Karelia Project NATIONAL ACTION NATIONAL DEMONSTRATION PROGRAM National health program Medical knowledge Public need for change Visible experiences, results National policy Diffusion
  57. 57. North Karelia Project MEDICAL KNOWLEDGE HARD PRACTICAL WORK SOCIAL & BEHAVIORAL THEORY COMMUNITY PROGRAM
  58. 58. Chow et Int J Epidemiol 2009;38:1580
  59. 59. 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
  60. 60. 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
  61. 61. 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
  62. 62. 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
  63. 63. Major elements of successful National Preventive Program 2 • National demonstration programme(s), focal point(s) • Policy decisions, intersectoral collaboration, legislation • Monitoring system • International collaboration
  64. 64. • 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 has shown
  65. 65. 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 North Karelia Project
  66. 66. FINNISH HEART PLAN How to reduce the number of cardiovascular disease morbidity and mortality by half PROMOTING CARDIOVASCULAR HEALTH AND PREVENTING CARDIOVASCULAR DISEASES REHABILITATION AND SECUNDARY PREVENTION STRAGEGIES OF EARLY DIAGNOSTICS AND TREATMENT - 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 - 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 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 Prevention Population strategy • Cardiovascular diseases and life style • Physical activity • Nutrition – Heart Symbol – Canteen catering • Weight control • Non-Smoking Health Promotion • 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

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