role of governments and society in the prevention of obesity and related chronic diseases chile,...
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ROLE OF GOVERNMENTS AND SOCIETY ROLE OF GOVERNMENTS AND SOCIETY IN THE PREVENTION OF OBESITY AND IN THE PREVENTION OF OBESITY AND RELATED CHRONIC DISEASESRELATED CHRONIC DISEASES
Chile, March 24-25, 2008
Pekka Puska, professor, MD, PhD, MPolScDirector General, National Public Health Institute (KTL)President Elect, World Heart Federation (WHF)Vice President, Int. Ass. of National Public Health Institutes (IANPHI)
CHILE, March 24-25, 2008 2
GREETINGS FROM FINLAND
CHILE, March 24-25, 2008 3 33
CHILE, March 24-25, 2008 4
GLOBAL PUBLIC HEALTH GLOBAL PUBLIC HEALTH IN TRANSITIONIN TRANSITION
Chronic diseases – especially Chronic diseases – especially cardiovascular diseasescardiovascular diseases
Leading health problem in Leading health problem in industrialized countriesindustrialized countries
Main killers and rapidly growing Main killers and rapidly growing problem in developing countriesproblem in developing countries
CHILE, March 24-25, 2008 5
Projected Main Causes of Death,Worldwide, All Ages, 2005
CHILE, March 24-25, 2008 6
CVD’S ARE TO A GREAT EXTENT CVD’S ARE TO A GREAT EXTENT PREVENTABLE DISEASESPREVENTABLE DISEASES
Medical evidence for prevention exists.Medical evidence for prevention exists.
Population-based prevention is the Population-based prevention is the
most most cost-effectivecost-effective and the only and the only
affordableaffordable option for major public option for major public
health improvement in CVD rates.health improvement in CVD rates.
Major changes in population rates can Major changes in population rates can
take place in a surprisingly take place in a surprisingly short time.short time.
CHILE, March 24-25, 2008 7
Prevention targets Prevention targets the population levels the population levels of most important of most important risk factors.risk factors.
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0 1000 2000 3000 4000 5000 6000 7000 8000
Occupational risk factors for injury
Unsafe health care injections
Vitamin A deficiency
Zinc deficiency
Urban air pollution
Iron deficiency
Indoor smoke from solid fuels
Unsafe water, sanitation, and hygiene
Alcohol
Physical inactivity
High Body Mass Index
Fruit and vegetable intake
Unsafe sex
Underweight
Cholesterol
Tobacco
Blood pressure
WORLDWORLDDEATHS IN 2000 ATTRIBUTABLE TO SELECTED DEATHS IN 2000 ATTRIBUTABLE TO SELECTED
LEADING RISK FACTORSLEADING RISK FACTORS
Number of deaths (000s)
Source: WHR 2002
CHILE, March 24-25, 2008 9
SIX OF THE SEVEN TOP DETERMINANTS SIX OF THE SEVEN TOP DETERMINANTS OF MORTALITY IN DEVELOPED COUNTRIES OF MORTALITY IN DEVELOPED COUNTRIES RELATE TO HOW WE EAT, DRINK AND MOVERELATE TO HOW WE EAT, DRINK AND MOVE
DIET AND PHYSICAL ACTIVITY, DIET AND PHYSICAL ACTIVITY, TOGETHER WITH TOBACCO AND TOGETHER WITH TOBACCO AND ALCOHOL, ARE KEY DETERMINANTS ALCOHOL, ARE KEY DETERMINANTS OF CONTEMPORARY PUBLIC HEALTHOF CONTEMPORARY PUBLIC HEALTH
CHILE, March 24-25, 2008 10
WHO’S NCD STRATEGY 2000WHO’S NCD STRATEGY 2000
NCD’s a priorityNCD’s a priorityPrevention keyPrevention keyIntegrated approach, targeting Integrated approach, targeting
main behavioural factors: diet, main behavioural factors: diet, physical activity and tobaccophysical activity and tobacco
WHO NCD ACTION PLAN (WHA 2008)WHO NCD ACTION PLAN (WHA 2008)
CHILE, March 24-25, 2008 11
DeterminantsDeterminants- sosial sosial - economicaleconomical- culturalcultural- politicalpolitical
Risk factorsRisk factorsbehavioural behavioural biologicalbiological
CVD/NCDCVD/NCD ConsequenciesConsequencies
HEALTH HEALTH PROMOTIONPROMOTION
PREVENTIONPREVENTION TREATMENT, TREATMENT, REHABILITATION, REHABILITATION, SEC. PREVENTIONSEC. PREVENTION
DIFFERENT LEVELS OF DIFFERENT LEVELS OF PREVENTION TARGETSPREVENTION TARGETS
POPULATIONPOPULATION HIGH RISKHIGH RISK PATIENTSPATIENTS
CHILE, March 24-25, 2008 12
SOUND COMBINATION OF POPULATION SOUND COMBINATION OF POPULATION STRATEGY WITH HIGH RISK STRATEGYSTRATEGY WITH HIGH RISK STRATEGY
1.1. POPULATION STRATEGY:POPULATION STRATEGY:
-- Greatest public health gainsGreatest public health gains
-- Cost effectiveCost effective
-- Results also in other health benefitsResults also in other health benefits
2.2. HIGH RISK STRATEGY:HIGH RISK STRATEGY:
- Great benefits to the persons - Great benefits to the persons concernedconcerned
- Effective use of health services- Effective use of health services
CHILE, March 24-25, 2008 13
LIFESTYLES IN KEY POSITIONLIFESTYLES IN KEY POSITION
Individual healthIndividual healthPopulation healthPopulation health
HOW TO INFLUENCE LIFESTYLES?HOW TO INFLUENCE LIFESTYLES?
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LIFESTYLES AND LIFESTYLES AND RISK FACTORS RISK FACTORS CAN CHANGE!CAN CHANGE!
CHILE, March 24-25, 2008 151515
61616
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North Karelia ProjectNorth Karelia ProjectPRINCIPLES FOR DEFINING PRINCIPLES FOR DEFINING THE INTERMEDIATE OBJECTIVESTHE INTERMEDIATE OBJECTIVES
• • Due to the chronic nature of CVD, Due to the chronic nature of CVD, the potential for the control of the problemthe potential for the control of the problemlies in lies in primary preventionprimary prevention
•• The risk factors were chosen on the basis ofThe risk factors were chosen on the basis ofbest available knowledgebest available knowledge: : - previous studies- previous studies- collective international recommendations- collective international recommendations- epidemiological situation in North Karelia- epidemiological situation in North Karelia
•• Chosen risk factorsChosen risk factors::- smoking- smoking- elevated serum cholesterol (diet)- elevated serum cholesterol (diet)- elevated blood pressure- elevated blood pressure
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FROM KARELIA TO NATIONAL ACTIONFROM KARELIA TO NATIONAL ACTION
• First province of North Karelia as a pilot First province of North Karelia as a pilot
(5 years), then national action (1972–77)(5 years), then national action (1972–77)
• Continuation is North Karelia as national Continuation is North Karelia as national
demonstration (1977–95)demonstration (1977–95)
• Good scientific evaluation to learn of the Good scientific evaluation to learn of the
experienceexperience
• Comprehensive national actionComprehensive national action
CHILE, March 24-25, 2008 19
EVALUATION / MONITORINGEVALUATION / MONITORING
- North Karelia – all FinlandNorth Karelia – all Finland
- Monitoring systemsMonitoring systems
• health behaviourhealth behaviour
• risk factorsrisk factors
• nutritionnutrition
• diseases, mortalitydiseases, mortality
CHILE, March 24-25, 2008 20
USE MAINLY BUTTER ON BREAD USE MAINLY BUTTER ON BREAD (men age 30(men age 30––59)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
CHILE, March 24-25, 2008 21
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
CHILE, March 24-25, 2008 22
USE MAINLY VEGETABLE OIL FOR USE MAINLY VEGETABLE OIL FOR COOKING (men age 30–59)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
%
23
SALT INTAKE IN FINLAND 1977–2002SALT INTAKE IN FINLAND 1977–2002
g/day
Year
Sources: Karvonen et al. 1977, Nissinen et al. 1982, Pietinen et al. 1981, Pietinen et al. 1990, Valsta 1992,
KTL/Nutrition Report 1995, KTL/ FINDIET 1997 and FINDIET2002 Studies, KTL/unpublished information
CHILE, March 24-25, 2008 24
SERUM CHOLESTEROL IN MENSERUM CHOLESTEROL IN MEN AGED 30–59 YEARSAGED 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
CHD MORTALITY IN ALL FINLAND AND CHD MORTALITY IN ALL FINLAND AND IN NORTH KARELIA, MEN AGED 35IN NORTH KARELIA, MEN AGED 35––6464
North Karelia
All Finland
start of the North Karelia Project
extension of the Project nationally
Source: Statistics Finland
- 85%
- 80%
0
100
200
300
400
500
600
700
6970 71727374757677787980 81828384858687 888990 91929394959697989900010203040506
Year
Per 100 000
25
CHILE, March 24-25, 2008 26
OBSERVED AND PREDICTED DECLINES IN CORONARY MORTALITY IN EASTERN FINLAND, MEN
-90
-80-70
-60
-50-40
-30
-20-10
0
1972 1977 1982 1987 1992 1997 2002 2007Year
%
ObservedPredictedCholesterolBlood pressureSmoking
CHILE, March 24-25, 2008 27
MORTALITY CHANGES IN NORTH KARELIA MORTALITY CHANGES IN NORTH KARELIA from 1969from 1969––71 to 200671 to 2006 (Men 35(Men 35––64 Years, Age Adjusted)64 Years, Age Adjusted)
Rate (per 100.000)Rate (per 100.000) Change fromChange from
19691969––71 71 20062006 19691969––71 to 71 to
20062006
All causesAll causes 15091509 572572 - 62%- 62%
All cardiovascularAll cardiovascular 855855 182182 - 79%- 79%
Coronary heart diseaseCoronary heart disease 672672 103103 - 85%- 85%
All cancersAll cancers 271271 9696 - 65%- 65%
Lung cancersLung cancers 147147 3030 - 80%- 80%
Rate (per 100.000)Rate (per 100.000) Change fromChange from
19691969––71 71 20062006 19691969––71 to 71 to
20062006
All causesAll causes 15091509 572572 - 62%- 62%
All cardiovascularAll cardiovascular 855855 182182 - 79%- 79%
Coronary heart diseaseCoronary heart disease 672672 103103 - 85%- 85%
All cancersAll cancers 271271 9696 - 65%- 65%
Lung cancersLung cancers 147147 3030 - 80%- 80%
CHILE, March 24-25, 2008 28
• A comprehensive, determined and theory-based community program can have a meaningful positive effect on riskfactors and life styles.
• Such changes are associated with respective favourable changes in chronic disease rates and health of the population.
• A major national demonstration program can be a strong tool for favourable national development in chronic disease prevention and health promotion.
North Karelia Project
CONCLUSIONSCONCLUSIONS
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Personal ResponsibilityPersonal Responsibility””Nobody can take better care of Nobody can take better care of your health than yourself”your health than yourself”
Public ResponsibilityPublic Responsibility””Make the healthy choices the easy Make the healthy choices the easy
ones”ones”(Ottawa declaration)
COMBING PERSONAL AND PUBLIC COMBING PERSONAL AND PUBLIC RESPONSIBILITIESRESPONSIBILITIES
CHILE, March 24-25, 2008 313131
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PUBLIC RESPONSIBILITYPUBLIC RESPONSIBILITY
POLICY INTERVENTIONSPOLICY INTERVENTIONS
CHILE, March 24-25, 2008 33
STRONG INTERACTION BETWEENSTRONG INTERACTION BETWEENDIFFERENT LEVELS NEEDEDDIFFERENT LEVELS NEEDED
GlobalGlobal
Regional EURegional EU
NationalNational
LocalLocal
CHILE, March 24-25, 2008 343434
CHILE, March 24-25, 2008 35
STRONG GLOBAL INFLUENCES – GLOBAL HEALTH STRONG GLOBAL INFLUENCES – GLOBAL HEALTH ACTIONS NEEDED: WHO GLOBAL STRATEGY ON ACTIONS NEEDED: WHO GLOBAL STRATEGY ON DIET, PHYSICAL ACTIVITY AND HEALTH ADOPTED IN 2004DIET, PHYSICAL ACTIVITY AND HEALTH ADOPTED IN 2004
CHILE, March 24-25, 2008 36
WE NEED STRONGER USE WE NEED STRONGER USE OF GLOBAL PUBLIC OF GLOBAL PUBLIC HEALTH INSTRUMENTS!HEALTH INSTRUMENTS!
Further developments with Further developments with Global Strategy on Diet and Global Strategy on Diet and Physical Activity.Physical Activity.
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NATIONALNATIONAL
Governments have a Governments have a basic responsibility basic responsibility
for public health.for public health.
CHILE, March 24-25, 2008 38
PARTNERSHIPS FOR NATIONAL PARTNERSHIPS FOR NATIONAL PUBLIC HEALTH WORKPUBLIC HEALTH WORK
Health servicesHealth servicesGovernments (national, local)Governments (national, local)Civil society (NGO’s)Civil society (NGO’s)Private sectorPrivate sector
International collaborationInternational collaboration
CHILE, March 24-25, 2008 39
PRIVATE SECTORPRIVATE SECTORFood, eating, physical activityFood, eating, physical activityCommercial issues are of increasing Commercial issues are of increasing
impact to public healthimpact to public healthHealth is increasingly important Health is increasingly important
business argumentbusiness argumentProduct development, marketingProduct development, marketingSocial responsibility? Regulation? Social responsibility? Regulation?
Market push?Market push?
CHILE, March 24-25, 2008 40
HEALTH SERVICESHEALTH SERVICES
High risk / population approachesHigh risk / population approachesHealth services in interaction with Health services in interaction with
other community activities and other community activities and general health promotion workgeneral health promotion work
Evidence Evidence –– based interventions based interventionsUse of IT technologyUse of IT technology
CHILE, March 24-25, 2008 41
CIVIL SOCIETYCIVIL SOCIETY
The role of civil society is The role of civil society is increasing in most countriesincreasing in most countries
NGO’s: mobilize people, NGO’s: mobilize people, serve people, watchdogs, etc.serve people, watchdogs, etc.
Push for childhood obesity to Push for childhood obesity to public / political agendapublic / political agenda
CHILE, March 24-25, 2008 42
During the last few years a great During the last few years a great number of strategies and plans for number of strategies and plans for evidence evidence – – based, effective based, effective prevention and health promotion prevention and health promotion have been produced.have been produced.
Many important priorities have Many important priorities have been identified.been identified.
CHILE, March 24-25, 2008 4343
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THE MAIN CHALLENGE IS THE MAIN CHALLENGE IS
NOT NOT WHATWHAT TO DO, TO DO,
BUT BUT HOW HOW TO DO!TO DO!
CHILE, March 24-25, 2008 45
IDENTIFYINGIDENTIFYING IMPLEMENTINGIMPLEMENTING
PRIORITIESPRIORITIES THEMTHEM
FROM PRIORITIES TO FROM PRIORITIES TO IMPLEMENTATIONIMPLEMENTATION
CHILE, March 24-25, 2008 46
STRONGER SUPPORT FOR STRONGER SUPPORT FOR IMPLEMENTATIONIMPLEMENTATION
Stronger public health Stronger public health infrastructuresinfrastructures
Stronger health surveillance / Stronger health surveillance / monitoringmonitoring
Innovative financial support Innovative financial support mechanismsmechanisms
CHILE, March 24-25, 2008 47
MEDICALMEDICAL KNOWLEDGE KNOWLEDGE
SOCIAL &SOCIAL & EFFECTIVE EFFECTIVE BEHAVIORAL BEHAVIORAL PROGRAMS PROGRAMS THEORY THEORY POLICIESPOLICIES
STRONG SUSTAINED SUSTAINED IMPLEMENTATIONIMPLEMENTATION
KEY ELEMENTSKEY ELEMENTS
CHILE, March 24-25, 2008 48
HEALTH MONITORINGHEALTH MONITORING
Power of monitoring Power of monitoring Feed back to people and Feed back to people and
decision makersdecision makersNeed to emphasize risk factors, Need to emphasize risk factors,
lifestyles, determinantslifestyles, determinants
CHILE, March 24-25, 2008 49
MAJOR ELEMENTS OF MAJOR ELEMENTS OF NATIONAL ACTION NATIONAL ACTION
• ResearchResearch• Health services (especially Health services (especially
primary health care)primary health care)• Demonstration programmesDemonstration programmes• Building coalitions Building coalitions • Schools, educational institutionsSchools, educational institutions
CHILE, March 24-25, 2008 50
MAJOR ELEMENTS OF MAJOR ELEMENTS OF NATIONAL ACTION NATIONAL ACTION
• Industry, business Industry, business
• Policy decisions, intersectoral Policy decisions, intersectoral collaboration, legislationcollaboration, legislation
• Monitoring: health Monitoring: health behavioursbehaviours, risk , risk factors, diseases factors, diseases
• International collaborationInternational collaboration
CHILE, March 24-25, 2008 51
PUBLICPUBLICPOLICYPOLICY
NATIONAL HEALTH NATIONAL HEALTH PROGRAMMEPROGRAMME
POPULATIONPOPULATIONPRIVATEPRIVATESECTORSECTOR
HOW TO PROMOTE POLICY CHANGES?HOW TO PROMOTE POLICY CHANGES?
CHILE, March 24-25, 2008 52
FOR SUCCESSFUL PREVENTIONFOR SUCCESSFUL PREVENTION
Strong leadership combined Strong leadership combined withwith
Good partnershipGood partnership
CHILE, March 24-25, 2008 535353
MUCHAS GRACIASMUCHAS GRACIAS
KIITOSKIITOS
Chile, March 24-25, 2008