Chnaging Behaviour at the population Level

"Changing Behaviour at the Population Level: the Karelia Project and why it worked"

Martin O’FlahertyChris Kypridemos

Department of Public Health and PolicyUniversity of Liverpool

Cancer in the Community workshop North West Cancer Research Centre. November 2014

This Talk

• The North Karelia Story

• Population level changes in Diet & Lifestyle :• Powerful • Fast• Cost-Saving

• Diet & Lifestyle: Beyond CVD

• What Finland taught us?

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

From Karelia to National Action

• First province of North Karelia as a pilot

(5 years), then national action (1972–77)

• Continuation is North Karelia as national demonstration (1977–97)

• Good scientific evaluation to learn of the experience

• Comprehensive national action

Pekka Puska, Director General04/21/2023


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

04/21/2023 Pekka Puska, Director General

Major Elements of Finnish National Action 2.

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

legislation• Monitoring system: health behaviours, risk

factors, nutrition, diseases, mortality• International collaboration



Example of Intersectoral work:Milk Consumption in Finland in 1970 and 2006 (kg per capita)

0

20

40

60

80

100

120

140kg

1960 1970 1980 1990 2000 2010

Whole milk

Whole form milk

Low fat milk

Skim 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• 10.000 kg less saturated

fat in their products 1975 1980 1985 1990 1995

YEAR

1. 6

1. 8

2. 0

2. 2

2. 4

Sa

lt c

on

ce

ntra

tio

n (%

)

Sa lt le v e l in Finnis h s a us a ge s


04/21/2023

Systolic blood pressure in women (30–59 y)

115

120

125

130

135

140

145

150

155

1972 1977 1982 1987 1992 1997 2002 2007

North KareliaKuopio provinceSouthwest FinlandHelsinki areaOulu provinceLapland province

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

mmHg

Pekka Puska, Director General

Serum Cholesterol in Men Aged 30–59 Years

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


Age-adjusted mortality rates of coronary heart disease in North Karelia

Puska P et al., M. The North Karelia project: from North Karelia to national action. [Helsinki]: National Institute for Health and Welfare; 2009.

A Massive Natural Experiment: Post Communist Central Europe

Economical& social changes

Graph shows standardized death rates due to all CVDs, people aged 25-74

Fat supply quantities by origin. Poland, 1977-2007

19771979

19811983

19851987

19891991

19931995

19971999

20012003

20052007

0

10

20

30

40

50

60

70

80

90

100

0

5

10

15

20

25

30

35

40

45

Animal products (all)vegetal products (all)

fat s

uppl

y qt

(g/c

apit

a/da

y)

Bandosz, O’Flaherty et al et al BMJ 2012;344:d8136

O’Flaherty & Capewell 2012, Lancet

Population Level Policies: Role of Structural Change

IMPACT Food Policy Model Collins et al Value in Health 2013

Saves more lives

Saves more money

Diet and

Smoking

CVD

Cancer

Dementia

Obesity and

DIabetes Oral Health

Osteoporosis

Diet, nutrition and the prevention of chronic diseases WHO Technical Report Series, No. 916 (TRS 916)

NCD PREVENTION

Deaths attributable to total effects of individual risk factors, by disease, US (in thousands)

Adapted from Danaei G et al. The preventable causes of death in the United States: comparative risk assessment of dietary, lifestyle, and metabolic risk Factors. PLoS Med. 2009 Apr 28;6(4):e1000058.

Mortality changes among men in North Karelia from 1969-71 to 2006 (per 100 000, men 35-64 years)

Mortality category Change in mortality rate from 1969-71 to 2006

Cardiovascular 80%

-Ischaemic heart disease 85%

-Cerebrovascular stroke 69%

Cancer 67%

All causes 63%

Puska P et al., M. The North Karelia project: from North Karelia to national action. [Helsinki]: National Institute for Health and Welfare; 2009.

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 and small changes – individual, – family, – community, – national – global


Finland Has Shown

• Influencing diet and smoking is a key issue

• Many results of prevention occur surprisingly quickly (CVD, diabetes)

• Other NCDs, including cancer will benefit.

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

Thank you and Questions!

https://www.liv.ac.uk/psychology-health-and-society/research/ncd-prevention-and-food-policy

NCD Prevention and Food Policy Research Group

Reserve Slides

“Downstream” prevention interventions targeting individuals

consistently achieve a smaller public health impact than “upstream” policies such as regulation or taxes...

23

An Effectiveness Hierarchy for Public Health

Effectiveness HierarchyEffects of different policy options

24

Downstream Upstream

S

ize

of

po

pu

lati

on

hea

lth

ben

efit

INTERVENTIONS

Downstream Upstream

0

5

10

15

20

25

30

35

Tobacco Control Scale (Joossens & Raw)TCS points

Joosens & Raw 2008

Tobacco Control Score (TCS)Estimated effects of different policy options

Burden of disease attributable to 20 leading risk factors in 2010expressed as a percentage of global disability-adjusted life-years (MEN)Global Burden of Disease Group. www.thelancet.com 2012 380 2245

Burden of disease attributable to 20 leading risk factors in 2010expressed as a percentage of global disability-adjusted life-yearsGlobal Burden of Disease Group. www.thelancet.com 2012 380 2245


Diet ≈ 40%


Diet>tobacco

+alcohol+inactivity

CVD Prevention:Policies can be rapid

CVD can change fastCVD death rates are DYNAMIC Evidence for rapid effects?

Capewell & O’Flaherty Lancet 2011 378 752

Potential reduction in deaths by achievement of dietary recommendations by disease and dietary recommendation, UK

* The impact of salt on CHD and stroke is mediated by changes in blood pressure. The impact on stomach cancer is direct

Adapted from Scarborough P et al. Modelling the impact of a healthy diet on cardiovascular disease and cancer mortality. J Epidemiol Community Health. 2012;66:5 420-426

CVD can change fastCVD death rates are DYNAMICEvidence for rapid effects

• DIET: Poland, Czech, E Germany, Cuba


200

400

600

P o l a n d

Deaths per

100,000

CHD mortality trends in Poland Zatonski & Willett BMJ 2005 331 187

200

400

600

P o l a n d

Deaths per

100,000

CHD mortality trends in Poland Zatonski & Willett BMJ 2005 331 187

Animal Fats

Subsidies

No Fat Subsidies.

Cheap vegetable oils

(Soya & rapeseed)

More Fruit

CVD can change fastCVD death rates are DYNAMICEvidence for rapid effects

• DIET: Poland, Czech, E Germany, Cuba• BP & CHOLESTEROL: tablet trials (3-6 months)

• cholesterol effect (1- 5 years) Law BMJ 1994

• 1940s Hunger Winters notched trend lines (1- 2 years)

• Smoke Free: Helena, Montana (3 months)

• PrediMed RCT


Potential reduction in deaths by achievement of dietary recommendations by disease and dietary recommendation, UK

* The impact of salt on CHD and stroke is mediated by changes in blood pressure. The impact on stomach cancer is direct


Potential reduction in deaths by achievement of dietary recommendations by age, sex and UK country


Risk Factors obviously powerful

but was it tablets or lifestyles??

Explaining the fall in coronary heart disease deaths in USA 1980-2000

Young et al Am J Prev Med 2010

-160,000

-140,000

-120,000

-100,000

-80,000

-60,000

-40,000

-20,000

0

Fewer CHD Deaths

Secular trends in CHD patients

Statins in Primary Prevention

Secular BP trends in CHD patients

Hypertension medications

Secular trends in Asymptomatic people (Diet)

Secular trends in Asymptomatic people

Cholesterol Reductions Blood Pressure Reductions

Fall in CHD deaths USA 1980-2000: Risk factor reductions in populations or in patients


-160,000

-140,000

-120,000

-100,000

-80,000

-60,000

-40,000

-20,000

0

Fewer CHD Deaths

Secular trends in CHD patients

Statins in Primary Prevention

Secular BP trends in CHD patients

Hypertension medications

Secular trends in Asymptomatic people (Diet)

Secular trends in Asymptomatic people

Cholesterol Reductions Blood Pressure Reductions


Fall in CHD deaths USA 1980-2000: Risk factor reductions in populations or in patients

Use of Butter on Bread (men age 30–59)

%

0

20

40

60

80

100

1972 1977 1982 1987 1992 1997 2002

North Karelia

Kuopio province

Southwest Finland

Helsinki area

Oulu province

Lapland province


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

%


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

Linear (24 hour urine, men)

Linear (24 hour urine,women)Linear (Calculated, men)

Linear (Calculated, women)


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


Major Elements of Finnish National Action 2.

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

legislation• Monitoring system: health behaviours, risk

factors, nutrition, diseases, mortality• International collaboration



-20000

-18000

-16000

-14000

-12000

-10000

-8000

-6000

-4000

-2000

0

CVD mortality reductions with different UK food policy options

UK 2006 baseline: 94,675 CHD deaths & 55,245 stroke deaths Transfats SatFats Salt Fruit & Veg

0.5% energy

1% energy

1portion

3portions

1% energy

3% energy

1gram

3 grams

CV

D

dea

ths

O’Flaherty et al WHO Bulletin 2012

Chnaging Behaviour at the population Level

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