Cancer in the Community workshop

North West Cancer Research Centre. November 2014

"Changing Behaviour at the Population

Level: the Karelia Project and why it
worked"
Martin OFlaherty
Chris Kypridemos
Department of Public Health and Policy
University of Liverpool

This Talk
The North Karelia Story
Population level changes in Diet & Lifestyle :
Powerful
Fast
Cost-Saving

Diet & Lifestyle: Beyond CVD

What Finland taught us?

69

North Karelia Project

Principles
Due to the chronic nature of CVD,
the potential for the control of the problem
lies in primary prevention
The risk factors were chosen on the basis of
best 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
(197277)
Continuation is North Karelia as
national demonstration (197797)
Good scientific evaluation to learn
of the experience
Comprehensive national action
4/28/15

Pekka Puska, Director General

From Karelia to 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,
NGOs, collaboration with media etc.)

4/28/15

Pekka Puska, Director General

From Karelia to National Action

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

4/28/15

Pekka Puska, Director General

Example of Intersectoral work:

Milk Consumption in Finland in 1970 and 2006 (kg per capita)
kg

140
Whole milk

120
100

Low fat milk

80
60

Whole form milk

40
20
0
1960
4/28/15

Skim milk

1970

1980

1990

Pekka Puska, Director General

2000

2010

Examples of intersectoral
work 2.

S a ltc o n c e n tra tio n (% )

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

Sa l
e v e l
t
n F i
i
n n i
s h s a u s a g e s

2 .
4

2 .
2

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

2 .
0

1 .
8

1 .
6

4/28/15

Pekka Puska, Director General

1 9 7 5

1 9

8 0

1 9 8 5

Y E AR

1 9 9 0

1 9 9 5

Systolic blood pressure in women (3059 y)

mmHg

North Karelia project evaluation and FINMONICA and the National FINRISK Studies 1972 - 2007
4/28/15

Pekka Puska, Director General

Serum Cholesterol in Men Aged 3059

Years
7,5

mmol/l

North Karelia
Kuopio
Turku/Loimaa
Helsinki/Vantaa
Oulu
Lapland

6,5
6
5,5
5
1972 1977 1982 1987 1992 1997 2002 2007
4/28/15

Pekka Puska, Director General

FINRISK Studies 1997 & 2002

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

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
100

45

90

40

80
70

35
30

60
25
fat supply qt(g/capita/day)

50
20

Animal products (all)

vegetal products (all)

40
30
20

15
10

10

Bandosz, OFlaherty et al et al
BMJ2012;344:d8136
OFlaherty & Capewell 2012, Lancet

Population Level Policies: Role of Structural Chang

Saves more lives

Saves more money

IMPACT Food Policy Model Collins et al Value in Health 2013

NCD PREVENTION
Cancer

Dement
ia

CVD

Diet
and
Smoking

Obesity
and
DIabete
s

Oral
Health

Osteopo
rosis

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

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.

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

4/28/15

individual,
family,
community,
national
global

Pekka Puska, Director General

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!

NCD Prevention and Food Policy Research
Group

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

Reserve Slides

An Effectiveness Hierarchy
or Public Health
Downstream prevention interventions
targeting individuals
consistently achieve a smaller public
health impact
than
upstream policies such as regulation
or taxes...
23

Size of population health benefit

Effectiveness Hierarchy
Effects of different policy options

Downstream

Upstream

INTERVENTIONS

24

Tobacco Control
TCS points

Score (TCS)
Estimated effects of different
policy
Joosens
& Raw 2008
options

Downstream

Upstream

Burden of disease attributable to 20 leading risk factors in 2010

expressed 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 2010

expressed as a percentage of global disability-adjusted life-years
Global Burden of Disease Group. www.thelancet.com 2012 380 2245

Burden of disease attributable to 20 leading risk factors in 2010

expressed as a percentage of global disability-adjusted life-years
Global Burden of Disease Group. www.thelancet.com 2012 380 2245

Diet 40%

Burden of disease attributable to 20 leading risk factors in 2010

expressed as a percentage of global disability-adjusted life-years
Global Burden of Disease Group. www.thelancet.com 2012 380 2245

Diet>t

obacco

+alcohol+inactivity

CVD
Prevention:
Policies can be
rapid

CVD can change fast

CVD death rates are DYNAMIC

Evidence for rapid effects?

Capewell & OFlaherty 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

CVD can change fast

CVD death rates are DYNAMIC

Evidence for rapid effects

DIET: Poland, Czech, E Germany, Cuba

Capewell & OFlaherty Lancet 2011 378 752

CHD mortality trends in

Poland

Zatonski & Willett BMJ 2005 331 187

Deaths
per
100,000

P o l a n d

CHD mortality trends in

Poland
Deaths
per
100,000

Animal
Fats
Subsidies

Zatonski & Willett BMJ 2005 331 187

No Fat Subsidies.
Cheap vegetable
oils (Soya & rapeseed)
More Fruit

P o l a n d

CVD can change fast

CVD death rates are DYNAMIC

Evidence for rapid effects

DIET: Poland, Czech, E Germany, Cuba

BP & CHOLESTEROL: tablet trials (3-6 months)
cholesterol effect (1- 5 years) Law
1940s Hunger Winters notched trend lines (1- 2 years)

BMJ 1994

Smoke Free: Helena, Montana (3 months)

PrediMed RCT
Capewell & OFlaherty 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

Potential reduction in deaths by

achievement of dietary
recommendations by age, sex and UK
country

Adapted from Scarborough P et al. Modelling the

impact of a healthy diet on cardiovascular disease
and cancer mortality. J Epidemiol Community

Explaining the fall in coronary heart

disease deaths in USA 1980-2000

Risk

Factors obviously powerful

but was it tablets or lifestyles??

Young et al Am J Prev Med

2010

Fall in CHD deaths USA 1980-2000:

Risk factor reductions in populations or in patients
Cholesterol Reductions

Secular trends
in CHD patients

Secular trends in
Asymptomatic
people (Diet)

Blood Pressure

Statins in
Primary
Prevention

Reductions
Hypertension
medications
Secular BP trends in
CHD patients

Secular trends in
Asymptomatic people

Young et al Am J Prev Med 2010

Fall in CHD deaths USA 1980-2000:

Risk factor reductions in populations or in patients
Cholesterol Reductions

Secular trends
in CHD patients

Secular trends in
Asymptomatic
people (Diet)

Blood Pressure

Statins in
Primary
Prevention

Reductions
Hypertension
medications
Secular BP trends in
CHD patients

Secular trends in
Asymptomatic people

Young et al Am J Prev Med 2010

Fall in CHD deaths USA 1980-2000:

Risk factor reductions in populations or in patients
Cholesterol Reductions

Secular trends
in CHD patients

Secular trends in
Asymptomatic
people (Diet)

Blood Pressure Reductions

Statins in
Primary
Prevention

Hypertension
medications
Secular BP trends in
CHD patients

Secular trends in
Asymptomatic people

Young et al Am J Prev Med 2010

Use of Butter on Bread

age 3059)
100

(men

%
North Karelia
Kuopio province
Southwest Finland
Helsinki area
Oulu province
Lapland province

80
60
40
20
0
1972 1977 1982 1987 1992 1997 2002
4/28/15

Pekka Puska, Director General

4/28/15

Pekka Puska, Director General

Use of Vegetable Oil for Cooking

age 3059)

(men

70

North Karelia
Kuopio province
Southwest Finland
Helsinki area
Oulu province
Lapland province

60
50
40
30
20
10
0
1972 1977 1982 1987 1992 1997 2002 2007
4/28/15

Pekka Puska, Director General

Salt intake in Finland 1977-2007

FinnDiet Study

4/28/15

Pekka Puska, Director General

From Karelia to 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,
NGOs, collaboration with media etc.)

4/28/15

Pekka Puska, Director General

From Karelia to National Action

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

4/28/15

Pekka Puska, Director General

CVD mortality reductions with

different UK food policy options
UK 2006

baseline:

94,675 CHD deaths & 55,245 stroke

deaths
0
Transfats
-2000

0.5%
energy

Salt
1

Fruit

gram

1%
1%

&

Veg

portion

energy

energy

CVD deaths

-4000

SatFats

-6000

grams

portions

-8000

-10000
-12000

3%
energy

OFlaherty et al WHO Bulletin 2012