Ncd prevention global and finnish perspectives

Seoul 15.11.2012

NCD prevention – Global and Finnish perspectives

Pekka Puska, MD, PhD, MPolScDirector General, National Institute for Health and Welfare (THL), FinlandPresident, Int. Association of National Public Health Institutes (IANPHI)Past President, World Health Federation (WHF)

12.04.23 Pekka Puska, Director General

Greetings from Finland

Pekka Puska, Director General12.04.23

Pekka Puska, Director General

GLOBAL PUBLIC HEALTH IN TRANSITION

Chronic non-communicable diseases – especially cardiovascular diseases

Leading health problem in industrialized countries

Main killers and rapidly growing problem in developing countries

04/12/23

10 million

15 million

20 million

25 million

High-income countries

Upper middle-income

Lower middle-income

Low-income countries

0.6M

0.5M

3.3M

2.3M

10.2M10.2M

3.3 M3.3 M3.0M

3.0M3.0M

3.0M

5.9M5.9M

2.3M

6.8 M6.8 M

3.7M

13.6M13.6M

1.1M0.9M

Low-income countriesGroup III - InjuriesGroup II – Other deaths from noncommunicable diseasesGroup II – Premature deaths from noncommunicable diseases (below the age of 60), which are preventableGroup I – Communicable diseases, maternal, perinatal and nutritional conditions

So

urce

:

Total number of deaths in the world

90% of premature deaths from NCDs occur in developing countries

12.04.23 4Pekka Puska, Director General

88

History in Finland

• Hardships of war and postwar years

• Relative increase in standard of livingGreat increase in CVD

• Attention to extremely high CVD mortality

• Determined action: North Karelia Project


699

1010Pekka Puska, Director General12.04.23

North Karelia ProjectPrinciples

• Due to the chronic nature of CVD, the potential for the control of the problemlies in primary prevention

• The risk factors were chosen on the basis ofbest available knowledge: - previous studies- collective international recommendations- epidemiological situation in North Karelia

• Chosen risk factors:- smoking- elevated serum cholesterol (diet)- elevated blood pressure (diet & treatment

• Community based approach to change lifestyles


Theory + hard work

• Theory:MedicalBehavioural, social

• Hard work: Practical and flexible work with

the community


From Karelia to National Action

• First province of North Karelia as a pilot (5

years), then national action (1972–97)

• Continuation is North Karelia as national

demonstration (1977–97)

• Good scientific evaluation to learn of the

experience

• Comprehensive national action


Major Elements of Finnish National Action 1.

• Research & international research collaboration

• Health services (especially primary health care)

• North Karelia Project, other demonstration programmes

• Health Promotion Programmes (coalitions,

NGO’s, collaboration with media etc.)

• Schools, educational institutions

04/12/23

• Industry, business – collaboration• Policy decisions, intersectoral collaboration,

legislation

• Monitoring system: health behaviours, risk factors, nutrition, diseases, mortality

• International collaboration

Major Elements of Finnish National Action 2.

04/12/23

Evaluation / Monitoring• North Karelia – all Finland

• Monitoring systems

• health behaviour

• risk factors

• nutrition

• diseases, mortality

• Monitoring developed to a national NCD monitoring system by THL


RESULTS

Lifestyles and public health can change


Butter consumption per capita in Finland

0

2

4

6

8

10

12

14

16

18

20

1955 1965 1975 1985 1995 2005

Co

nsu

mp

tio

n (

kg p

er c

apit

a)


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

North Karelia

Kuopio province

Southwest FinlandHelsinki area

Oulu province

Lapland province

%

WHO meeting, Helsinki 6 - 7 September 2010

04/12/23

Salt intake in Finland 1977-2007FinnDiet Study


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

Lin. (24 hour urine, men)

Lin. (24 hour urine, women)

Lin. (Calculated, men)

Lin. (Calculated, women)

Serum Cholesterol in Men Aged 30–59 Serum Cholesterol in Men Aged 30–59 YearsYears

FINRISK Studies 1997 & 2002

mmol/l

5

5,5

6

6,5

7

7,5

1972 1977 1982 1987 1992 1997 2002 2007

North Karelia

Kuopio

Turku/Loimaa

Helsinki/Vantaa

Oulu

Lapland


12.04.23

Systolic blood pressure in Systolic blood pressure in women (30women (30–59 y)59 y)

115

120

125

130

135

140

145

150

155

1972 1977 1982 1987 1992 1997 2002 2007

North Karelia

Kuopio province

Southwest Finland

Helsinki area

Oulu province

Lapland province

North Karelia project evaluation and FINMONICA and the National FINRISK Studies 1972 - 2007

mmHg



Change in age-adjusted mortality rates Finland, males aged 35–64 (per 100 000 population)

extension of the Project nationally

start of the North Karelia Project

North Karelia -85%

All Finland -80%

Rate per 100 000

1969-1971

2006 Change from 1969-1971 to 2006

All causes 1328 583 -56%

All cardiovascular

680 172 -75%

Coronary heart disease

489 103 -79%

All cancers 262 124 -53%

Coronary heart diseaseCoronary heart disease

Gain of some 10 healthy years in Finnish popupaltion

Gain of some 10 healthy years in Finnish popupaltion


Observed and Predicted Declines in Coronary Mortality in Eastern Finland, Men

-90

-80-70

-60

-50-40

-30

-20-10

0

1972 1977 1982 1987 1992 1997 2002 2007Year

%

ObservedPredictedCholesterolBlood pressureSmoking

Pekka Puska, Director General04/12/23

RESULTS: SUMMARY• Big change in lifestyles and biological risk

factors

• Big reduction in premature NCD mortality and incidence

• Increased subjective health

• Healthy ageing

x x x

NCD changes explained to great

extent by risk factor changes


12/04/23 Pekka Puska, Director General 25


DISCUSSION ON STRATEGIES(Finland and WHO)

Community-based project

(pilot, demonstration, model)

National programme and policies


Sound Combination of Population Strategy With High Risk Strategy

1. Population strategy:- Greatest public health gains- Cost effective- Results also in other health benefits

2. High risk strategy:

- Great benefits to the persons concerned

- Effective use of health services

Comprehensive action and partnership for national NCD prevention

• Governments, policies

(national, local)

• Health services

• Civil society (NGOs)

• Private sector

• Media

• International collaboration

(esp. WHO)


Cornerstones of NCD prevention and control (WHO global strategy)• Attention to behavioural risk factors

– Tobacco use– Unhealthy diet– Physical inactivity– Harmful use of alcohol

• Monitoring and surveillance of – Risk factors and diseases– Preventive actions

• Redirection of health services– Prevention– Chronic care model



Integrated PreventionCommon Risk Factors

TOBACCO USETOBACCO USE

UNHEALTHY DIETUNHEALTHY DIET

PHYSICAL PHYSICAL INACTIVITYINACTIVITY

ALCOHOLALCOHOL

CVD

DIABETES

CANCER

COPD

MUSCULOSCELETAL

ORAL HEALTH

12.04.23

Redirection of health services

12.04.23 Pekka Puska, Director General 32

• Reorientation and strengthening of health systems• Primary health care:

”Now more than ever” (WHR 2008)

• Special emphasis for NCDs• Chronic care model• Preventive practices

Surveillance/monitoring • Monitoring of

DiseasesRisk factors/behavioursDeterminantsPrevention & control process

(health service response)

• National institutional base for surveillance and links with national health monitoring

• International standardization and collaboration

• Active use of surveillance results: Feed-back, communication


• ”Best buys”: NCD mortality trendRisk factor trends

During the last few years a great number of strategies and plans for evidence-based, effective prevention and health promotion have been produced


Many important priorities have been identified


IDENTIFYINGIDENTIFYING IMPLEMENTINGIMPLEMENTING

PRIORITIESPRIORITIES THEMTHEM

FROM PRIORITIES TO IMPLEMENTATION

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Implementation gap

Intersectoral work towards prevention- ”Health in all policies”

• People’s lifestyles are influenced by decisions in different sectors of society (much of them beyond the health sector)

• Health in general and NCD prevention in particular should be taken into account in decisions made by different sectors (health impact assessment)

• Social change process combining government policies, expert guidance, broad health promotion and mobilization of people


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

Change in fat content of Finnish cow milk


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:

• 40.000 kg less salt

• 100.000 kg less saturated

fat in their products 1975 1980 1985 1990 1995

YEAR

1.6

1.8

2.0

2.2

2.4

Salt

co

ncen

tratio

n (

%)

Salt level in Finnish sausages


BERRY PROJECT IN NORTH KARELIA

04/12/23

• To promote berry farming, product development and consumption

• Dairy farmers could switch over to berry farming

• Financing from Ministries of Agriculture and Commerce

www.sydanmerkki.fi

The Finnish Heart Symbol

Fruits and Vegetables – SupermarketsFruits and Vegetables – Supermarkets

04/12/23

0 1000 2000 3000 4000 5000 6000 7000 8000

Occupational risk factors for injury

Unsafe health care injections

Vitamin A deficiency

Zinc deficiency

Urban air pollution

Iron deficiency

Indoor smoke from solid fuels

Unsafe water, sanitation, and hygiene

Alcohol

Physical inactivity

High Body Mass Index

Fruit and vegetable intake

Unsafe sex

Underweight

Cholesterol

Tobacco

Blood pressure

WORLDWORLDDeaths in 2000 Attributable to Selected Deaths in 2000 Attributable to Selected Leading Risk Leading Risk

FactorsFactors

Number of deaths (000s)

Source: WHR 2002


Seven of the Nine Top Determinants of Seven of the Nine Top Determinants of Mortality in the World Relate to How Mortality in the World Relate to How We Eat, Drink and MoveWe Eat, Drink and Move

Diet and physical activity, together Diet and physical activity, together with tobacco and alcohol, are key with tobacco and alcohol, are key determinants of contemporary determinants of contemporary public healthpublic health


UN high-level summit on NCDsNew York Sept 2011

• Preceeded by Ministerial Conference in Moscow (April 2011).

• Political declaration• Action on global NCD

prevention and control”• WHO’s leadership,

intersectoral support

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RECENT POLITICAL SUPPORT

44Pekka Puska, Director General

2000

2003

2004

2008

Global Strategy for the Prevention and Control of Noncommunicable Diseases

Global Strategy on Diet, Physical Activity and Health

Action Plan on the Global Strategy for the Prevention and Control of NCDs

The journey to scale up global action

2010

2009

2011

Global Strategy to Reduce the Harmful Use of Alcohol

WHO Global Status Report on NCDs

UN Political Declaration on NCDs12.04.23 45Pekka Puska, Director General

8th Global WHO Conference on health promotion - “Health in all policies”

From Ottawa to Helsinki (June 2013)


47

31

Finland Has Shown

• Prevention of cardiovascular diseases is possible and pays off

• Population based prevention is the most cost effective and sustainable public health approach to CVD control

• Prevention calls for simple changes in some lifestyles (individual, family, community, national and global level action)

• Influencing diet and especially quality of fat is a key issue

• Many results of prevention occur surprisingly quickly

(CVD, diabetes) and also at relatively late age

• Comprehensive action, broad collaboration with dedicated leadership and strong government policy support

04/12/23

The North Karelia/Finland experience• Supports and has interacted much with

the WHO NCD strategy:– Integrated prevention–FCTC, Diet & physical activity strategy

• Happy about the recent political support to upgrading of NCD prevention–UN NCD Summit in September 2011

in New York–Follow up work under WHO leadership


• Chronic disease (NCD) prevention and control is possible and pays off

• Population based NCD prevention by appropriate policies and health promotion activities is the most effective way to improve public health

• Influencing NCD related lifestyles is also the way to support sustainable social and economic development


Conclusion


Thank you

Health & Medicine

Ncd prevention global and finnish perspectives