Background
In 1972, the Government of Finland identified an alarmingly high rate of cardiovascular disease in its population, with the province of North Karelia, in the eastern part of the country at the top of the list. The inhabitants of North Karelia had a high level of fitness and smoking was no more prevalent than in other communities, so diet was soon identified as the predominant factor. Consumption of high fat dairy products such as butter, cream, whole milk and cheese was widespread. The diet was also lacking in fruits and vegetables.
The North Karelia Project
In response, a national project was launched to reduce the risk factors for heart disease and further reduce the number of deaths from cardiovascular disease. The ‘North Karelia Project’ as it became known was set up as a community-based program to reduce the risk factors for cardiovascular disease. In Finland, health centres provide the primary health services. At the start of the program, the project was incorporated into the work of health centre staff with no requirement for extra staff.
Healthcare personnel, including doctors and nurses, were trained to give advice on quitting smoking, to give dietary advice and to conduct blood pressure and cholesterol measurements. Training was also given to other groups working with health issues such as home economic teachers, social workers and counsellors. A variety of activities were set up over the years to increase awareness and take action against the risk factors of cardiovascular disease. These included:
The lay leaders programme educated active people in the community to pay attention to health related issues, for example by discussing smoking and diet with the people they met, promoting smoke free meeting facilities or urging local grocery stores to improve the variety of fruits and vegetables on sale. Another imaginative initiative involved a project that encouraged people to grow berries. Berries grow well in the Finnish climate and are known for their valuable nutritional content. Most of the population changed from drinking whole milk to the consumption of low fat or skimmed milk. The consumption of whole milk dropped from 70% to 14%. As a result of these combined efforts, cholesterol levels decreased significantly.
Anti-smoking legislation was passed in the 1970s where Finland eliminated all tobacco advertising and prohibited smoking in most public places indoors. Interestingly tobacco taxes were ring-fenced for anti-smoking programmes.
The results
There has been a remarkable decline in heart disease in North Karelia and in Finland as a whole. There has also been a reduction in cancer deaths. Finland has reduced its incidence of heart attacks by 75% since the early 1970s. The mortality rates remain still quite high compared to some other countries but results have still been tremendous and this is clearly due to the reduction in risk factors.
Of the single risk factors, reduction in serum cholesterol levels has had the greatest impact. It has been estimated that as a result of the North Karelia Project around 3,800 premature deaths have been prevented in North Karelia and 50,000 in the whole of Finland.
Conclusions
The 25 year results and experiences of the North Karelia Project show the major impact on health-related lifestyles and on population risk factor levels and that this development, indeed, leads to reduced disease rates and improved health of the population. By 1995 the annual mortality rate of coronary heart disease in North Karelia in the working age population had fallen approximately 75%, compared with the rate before the Project. What this initiative shows is that political will needs to be combined with public education about the vital role that diet and lifestyle plays in our overall health.