by Sirpa Seppanen, Nutritionist

How Finland ate its way to better health
In the 1960s Finnish men had the world’s highest death rate from heart disease. Heart disease was a problem all over Finland but the death rate was especially high in the province of North Karelia, an area in the eastern part of the country.

The people of North Karelia had a quite high level of fitness and smoking was not more prevalent than in other communities. However, the problem was in the diet. The region of North Karelia was dominantly farming and the 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.

What was the response?
A co-ordinated response to the alarming ischeamic heart disease rate in Finland came in 1972, as people realised that it was not normal to suffer from chest pain before reaching the age of 50.

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’ took its name from the province in which it was launched. It was going to act as a pilot study for the rest of Finland.

What are the main risk factors for heart disease?
Elevated blood pressure, blood cholesterol and smoking are the main risk factors for heart disease. Although genetics have some influence on developing hypertension and high blood cholesterol levels they can be largely affected by changes in diet and lifestyle.

How was the project implemented?
A community-based program was set up to reduce the risk factors for cardiovascular disease. In the Finnish health care structure health centres provide the primary health services. At the start of the program no extra personnel were hired and the project was incorporated into the work of health centre staff.

Health care centre personnel – 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 and innovative programs were set up over the years to increase awareness and take action against the risk factors of cardiovascular disease. These included, for example:
• Programmes at workplaces to lose weight, quit smoking or to increase
  the availability of vegetables at work place canteens.
• Several nationwide TV series were broadcast where a group of people
  would volunteer to make healthy changes in their lifestyles with the
  help of experts.
• Cholesterol-lowering competitions were organised between villages in
  North Karelia.
• 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.
• Anti-smoking legislation was passed in the 1970s, which is more
  radical than Ireland, 30 years and countless thousands of smoking-related
  deaths later, has yet managed. Finland eliminated all tobacco advertising
  and prohibited smoking in most public places indoors. Tobacco taxes
  were devoted to anti-smoking programmes. Special smoking cessations
  services were introduced
• The Project worked together with food manufacturers and supermarkets to facilitate
  dietary changes. The industry focused on the development of low fat
  dairy and meat products and the reduction of salt in a number of food
  items. There was also close collaboration between the project and
  vegetable oil product manufacturers to produce healthier spreads.
• 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.

What were the effects on the risk factors?
There have been major changes in dietary habits in North Karelia and Finland as a whole. The diet that used to be very high in saturated fat and salt now has one of the lowest fat contents in Europe and an average salt level. As an example in 1972, in the beginning of the project, 80% of the people used butter on bread and by the end of the study only one in ten people used butter and most people had changed to low fat spreads.

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.

Many people in North Karelia suffered from hypertension and most were not aware of it or it was not being treated. People with hypertension were advised to lose weight, reduce salt intake and modify fat intake. Blood pressure and cholesterol levels measurements became much more common and as a result, blood pressure decreased.

As a result of the anti-smoking policies, smoking among men fell by a third. Smoking increased among women but it is still on a very low level, with fewer than one in six women smoking.

Amazing decline in cardiovascular deaths
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.
The North Karelia project lasted for over 20 years and there have been major changes in the health behaviour of the people of North Karelia and the changes have reflected in the public health of Finland as a whole.

The North Karelia Project shows that public health education can significantly reduce development of ‘lifestyle’ diseases, mainly cardiovascular disease but also cancer. It has provided a model for numerous similar projects around the world, and offers hope that Ireland can tackle its high level of heart disease and premature death.

For this to succeed, political will needs to be combined with public education about the vital role that diet and lifestyle plays in our overall health. With growing public concern at the cost of the health sector in Ireland, perhaps the real beauty of this approach is that it is highly cost-effective and doesn’t require high-tech medicine and billions of euros to make a very real difference.

The author, a native of Finland, works as Nutritionist with Glanbia

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