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After 25 Years -
North Karelia
Project Shows The World How To Reduce Heart Disease
By Gerry Luoma Henkel
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in the early 1970's, in Joensuu and other smaller villages in North Karelia,
Dr. Pekka Puska (on right) and his colleagues would stand for hours
in supermarkets handing out leaflets that described the benefits of eating
better, smoking less, and exercising more. It was not an easy task for Puska
and his co-workers to change the attitudes of the customers in the stores
- many Finnish eating habits at that time worked against recommended dietary
changes. Butter, cheese, cream and whole milk were regarded as healthy, especially
for children. Finland was a butter and milk producer. Butter and milk production
was subsidized by the government. These factors and others led to North Karelia
having a heart-disease rate twice that of Finland as a whole.
Gautam Naik, a staff reporter for the Wall Street Journal writes about Pekka
Puska’s approach:
(He) ...figured that heart disease, rather than being a problem for just a few high-risk individuals, related to the lifestyle of the entire community. So the whole population would have to be persuaded to change its habits....Part of that meant getting local residents to see health care in a different way. People had rarely been told to take responsibility for their health, whether by watching their diet or exercising. If people got sick, they went to the doctor -- and that was that. The first challenge for Dr. Puska's team was to alter the local diet. In 1972, a typical meal in North Karelia consisted of high-fat dairy products and sausages. Anything green was dismissed as "food for animals," says the 57-year-old Dr. Puska. So he and his colleagues began by visiting dairy farmers and other food producers, touting the health benefits of a low-saturated-fat diet, and encouraging them to diversify into crops such as berries and apples. Although the project was organized by the Finnish government, the doctors had no power to coerce the farmers into changing their ways. They relied on simple persistence, hoping that the logic of the arguments would wear down farmers' resistance. In most cases, it took many visits to get people to come around. One sausage maker agreed to switch to ingredients such as mushrooms instead of pork, but only after he had a heart attack himself.
Naik also writes
that "Dr. Puska appeared on a weekly TV show where he'd take the blood
pressure and cholesterol readings of about 10 North Karelians – then
exhort them to change their habits. The television series, which ran on and
off for 15 years, became something of an obsession for some Finns. One day,
when a new episode was about to air, Dr. Puska's neighbor said to him: 'Hey,
Pekka! I'm dying of curiosity. Has that girl from the previous show managed
to stop smoking?' "
These efforts by Dr. Puska and others were all a part of a major effort called
the North Karelia Project. It was launched in 1972 to reduce the exceptionally
high coronary heart disease mortality rates in the area. In co-operation with
local and national authorities and experts, as well as with World Health Organization,
the Project was designed and implemented to carry out comprehensive intervention
through the community organizations in the area, and the action of the people
themselves.
Over the years the scope of the Project has been enlarged to promote integrated
prevention of major noncommunicable diseases (cancer, diabetes, etc.) as well
as health promotion in general, and prevention of risk related lifestyles
in childhood and youth. The Project has undergone a comprehensive evaluation,
and has now become a major demonstration program in Finland and internationally.
The
published results of the North
Karelia Project show how over the 25 year period major changes have taken
place. Among men in North Karelia, smoking was greatly reduced and dietary
habits have markedly changed. In 1972, a little more than half of middle-aged
men in North Karelia smoked. In 1997 the percentage had fallen to less than
a third.
In the early 70's use of vegetables or vegetable oil products was very rare;
now it is very common. In 1972 about 9 out of 10 North Karelians put butter
on their bread. Today it is less than 1 in 10. The dietary changes have led
to about a 17% reduction in the mean serum cholesterol level of the population.
Elevated blood pressures have been brought well under control and leisure
time physical activity has been increased. Among women, similar changes in
dietary habits made important changes in cholesterol and blood pressure levels.
Because of the Project, North Karelian men and women are living longer. By
1995 the annual mortality rate of coronary heart disease among men under 65
years old was reduced by about 73% from the pre-program years (1967-71). Among
women, the reduction in deaths from cardiovascular disease has been of the
same magnitude as among men.
Since the 1980's these favorable changes began to develop throughout all Finland.
Greatly reduced cardiovascular and cancer mortality has led to greater life
expectancy: approximately 7 years for men and 6 years for women. Associated
with these risk factor and lifestyle changes, the general health status of
the people has greatly improved. A separate analysis has shown that the reduction
in serum cholesterol level has been the strongest contributor.
According to Dr. Pekka Puska, there were difficulties all along the way. In
a summary of the Project, he writes:
In the early years the concept of community based prevention was alien, especially to the cardiological community that wasn't happy about the funding of the project. North Karelia was also a low socio-economic area with scarcity of medical resources and with many socio-economic problems in the 70's. The local culture was in many ways traditional, resisting change. Dairy farming was a major source of livelihood; butter was the local product much liked. The national dairy industry made major efforts and used resources to protect their economic interests.
Now the World
Health Organization is setting up trial versions of the program around the
globe, from China to South America to the Middle East. One of them is in Olmsted
County in southern Minnesota. According to Tom Kottke, a cardiologist at the
Mayo Clinic in Rochester, Minn., and project director of CardioVision
2020, "The solution they found in North Karelia is extremely relevant
for us".
CardioVision, which started two years ago and had a budget last year of $250,000,
aims to make Olmsted County the most "heart healthy" county in the
U.S. within 20 years. Among the initiatives to achieve this goal: walking
contests and a program that sends volunteers to local restaurants to calculate
the sodium, calorie and saturated-fat content of each entrée. Meals
deemed to be especially healthy are then identified on the menu as such.
Other projects developed by WHO with the help of Dr. Puska are in Tianjing,
China; Valparaiso, Chile; Isfahan, Iran; and Nizwa, Oman. (Puska is now the
Director of Noncommunicable Disease Prevention and Health Promotion for the
World Health Organization.)
The Wall Street Journal also reported about a project about 125 miles from
North Karelia.
"Officials in the district of Pitkaranta, Russia, started noticing the
success the Finns were having and asked for their help. The first step: educating
nurses, doctors and teachers in the community of 780,000 about the benefits
of a healthier lifestyle." But, just as in Finland, the Journal reports
that there "...is a stubborn resistance to change. Last November, for
example, while recuperating from a heart attack, Anatolii Pozhilov got a visit
from a health-care worker, who warned the 50-year-old mechanic to stop eating
high-fat foods, smoking and downing an entire bottle of vodka at a time. Mr.
Pozhilov shrugged and flicked open a pack of cigarettes lying by his bed.
"A Russian man smokes and drinks till he's 50," he said. "Then
he's sorry."
Other Causes
and Cures for Heart Disease
According to medical historians, before 1900 very few people died of heart
disease - heart attacks did not exist - at least not in the medical books.
Doctors at that time never heard the word coronary thrombosis. The first reported
heart attack occurred in 1896 and the condition did not even have a name.
Several years later the New England Journal of Medicine did a write up about
this new and curious but very rare condition and they called it myocardial
infarct. Since then heart disease has become the number one killer in the
United States. Today half the population of America dies from cardiovascular
disease.
What happened during the last 100 years that has made heart disease the major
cause of death? The North Karelian Project has shown that by dealing on a
community wide level with the lifestyle issues of diet, tobacco, and exercise,
the rate of death by heart disease can be reduced significantly.
It must be noted however, that other researchers into the causes of heart
disease believe there are other very important factors to consider. For instance,
genetic heredity plays a significant role according to some researchers.
One other factor also plays a large role according to others: overwhelming
stress - not the everyday kind that we all have (and need according to some
observers), but the kind that could best be termed "distress". Those
who believe that stress is a major reason for heart disease argue that we
have become a planet of human beings who are isolated from each other. The
result is that we become lonely people with, literally, "broken hearts"
that lead to malaise and disease.
Mental, emotional, and even physical distress, according to many commentators
such as Dr. Dean Ornish, create conditions that lead to heart disease, heart
attacks, and even death. The solution they say is to learn how to remove the
excess harmful tension from a person's life through practices such as relaxation
methods, yoga, meditation, prayer, play, dance, etc.
This approach to reversing heart disease does not appear to play a specific
role in the North Karelian model.
There are studies, such as a recent one in Scotland, that challenges the idea
that stress is a cause of heart disease. In the May 25 issue of the British
Medical Journal there is a report about researchers in Scotland who followed
a group of men for more than 20 years and found that those who reported the
most stress actually died less often from heart attacks and had fewer objective
signs of heart disease. These men also tended to smoke more, drink more, and
exercise less than other men in the study.
Lead author John Macleod, MD, and colleagues found that men reporting more
stress tended to be more socially and economically advantaged. These men reported
more symptoms of heart disease, but they also experienced fewer heart attack
deaths over the study period. This led the authors to conclude that the protective
benefits of affluence, such as better access to medical care, help to offset
an unhealthy lifestyle.
Their conclusion brings us to another school of thought about the reason why
heart disease has become the major killer of humans throughout the world.
This school of thought regards stress also as a part of the problem, but pushes
for a solution in another direction - politically by actively working for
social and economic justice.
Social Justice is
Good for Our Hearts: Why Societal Factors – Not Lifestyles – are
Major Causes of Heart Disease in Canada and Elsewhere is a report
published by the Center for Social Justice in Toronto, Ontario.
In the summary of the report, author Dennis Raphael writes: "Poor conditions
lead to poorer health. An unhealthy material environment and unhealthy behaviors
have direct harmful effects, but the worries and insecurities of daily life
and the lack of supportive environments also have an influence...An extensive
body of research now indicates that the economic and social conditions under
which people live their lives, rather than medical treatments and lifestyle
choices, are the major factors determining whether they develop cardiovascular
disease. One of the most important life conditions that determine whether
individuals stay healthy or become ill is their income. In addition, the overall
health of North American society may be more determined by the distribution
of income among its members rather than the overall wealth of the society."
Even though there may be significant factors that are not specifically addressed
by the North Karelia Project (the role of stress, and the role of social injustice),
it is obvious that the project has had a major impact in the world, mainly
because of the work of Pekka Puska.
(Much of the material for this article is based on the Wall Street Journal
piece written by Gautam Naik, published on January 14th. The title is “Doctors
Cajole Whole Towns To Change Unhealthy Habits.)