North Karelia Project Research Articles

Prevalence of risk factors for non-communicable diseases among the adult population of several administrative districts of Moscow before the COVID-19 pandemic

Introduction. Currently, increased attention of public policy is paid to non-communicable diseases, which are the leading causes in the structure of mortality, disability and morbidity of the population. In this connection, many government programs are currently being implemented to prevent non-communicable diseases and correct risk factors. Finland's experience in the implementation of the North Karelia project has shown the effectiveness of the prevention of noncommunicable diseases through interagency cooperation. As a result, one of the priority areas of work of the Ministry of Health of the Russian Federation has become the formation of a unified system of strengthening public health. In 2020, the Moscow Department of Health approved the Regional Program for Strengthening the Public Health of the Moscow Population, on the basis of which district programs began to be developed. Objective. Analysis of the prevalence of risk factors for non-communicable diseases among the adult population of the Northern, North-Eastern and Southern administrative districts for 2017–2019. Materials and methods. The materials used were programs to strengthen the public health of the population of the Northern Administrative District, Northern Eastern Administrative District and the Southern Administrative District of Moscow. Results. The largest number of pathological abnormalities in the course of a preventive medical examination and clinical examination is revealed during a survey (questionnaire) and examination by a general practitioner, i. e. at the beginning and at the end of the first stage of clinical examination. According to the results of preventive medical examinations and clinical examination, the greatest contribution (more than 50 %) is made by such risk factors as inappropriate nutrition, low physical activity and overweight, the smallest proportion was hyperglycemia (from 1.2 % to 2.9 %). A high percentage of identified risk factors for non-communicable diseases is noted in the age group 39–60 years old (mainly among women), about 40 % – in the elderly population (over 60 years old).

The North Karelia Project (1972-1997) and the Origins of the Community Approach to Cardiovascular Disease Prevention.

Community-based risk factor modification is today an established approach to chronic disease control and public health practice. This article analyzes the shaping of the North Karelia Project (NKP), an early and influential formulation of the community approach that focused on coronary heart disease prevention in Finland. Instead of targeting only high-risk individuals, NKP aimed to change the culture of the local community. On the basis of archival material and interviews, I first trace the multiple origins of the notion of community in NKP, which combined "internal" factors (local risk factor distribution, the role given to the social environment in chronic disease prevention) and "external" influences (regional origin of the initiative, World Health Organization and national policy concepts of community control and primary health care). Second, I describe the shape of the community intervention in NKP. The project foregrounded social relationships as a way to educate the public and influence norms guiding individual behaviors while subordinating environmental changes of a more structural nature.

Becoming the North Karelia Project: The Shaping of an Iconic Community Health Intervention in Finland (1970–1977)

Summary The article describes the shaping of an iconic public health intervention, the North Karelia Project (NKP) in Finland in the 1970s. NKP is widely hailed as a landmark project, contributing significantly to the development of the community approach to chronic disease prevention. This approach targets comprehensively a specified health problem in a circumscribed area among the whole population, not only high-risk individuals. Based on published and archival material as well as interviews with a few key actors, the article shows how two interlinked tensions shaped the project: the first between rigorous scientific inquiry and politically motivated practical healthcare development in a disadvantaged area and the second between a broad community approach and a focus on individualised health behaviour. These tensions played out in the planning, funding and administrative structure of NKP, were the key source of criticism of it and have affected the possibilities to evaluate its results.

The North Karelia Project: Prevention of Cardiovascular Disease in Finland Through Population-Based Lifestyle Interventions.

The North Karelia Project was started in 1972 as a response to the high cardiovascular mortality among men in North Karelia, Finland's easternmost province. Prevalent cardiovascular disease risk factors in the province included elevated serum cholesterol, hypertension, and smoking. Through a sociobehavioral framework utilizing community-based interventions and national-level policy changes and legislation, the project targeted lifestyle changes as a means to alleviate cardiovascular disease risk factors. Diet recommendations included minimizing the use of saturated fats and decreasing salt intake. Another target of the project was to reduce the prevalence of smoking. As a result of the lifestyle interventions that continued beyond the initial 5 years of the project and then expanded to all of Finland, there were significant reductions in serum cholesterol levels, hypertension, smoking prevalence, and cardiovascular disease mortality. The North Karelia Project demonstrates that successful population-based lifestyle interventions serve as a sustainable public health solution to the growing chronic disease burden.

P6222Changes in main CVD risk factors in Finland 1992–2017

Abstract Background Systematic monitoring of cardiovascular disease (CVD) risk factors started in eastern Finland already in the 1970s as part of the North Karelia Project. Later on risk factor monitoring was extended to other parts of the country. Purpose In this study we report the trends of main CVD risk factors in Finland from 1992 to 2017. Methods Study population consists of a population-based random sample of 31 402 men and women aged 25–64 years who participated in the FINRISK Studies from 1992 to 2012, and in the FinHealth Study in 2017. Data collection was done every five years. Participation rate decreased from 76% in 1992 to 56% in 2017. Study protocol included self-reported questionnaire data on smoking and other health behavior, measurements of height, weight and blood pressure, and venous blood sample for laboratory analysis. Blood pressure was measured two times, and the average of the measurements was calculated, total serum cholesterol was analyzed using enzymatic method, and LDL cholesterol was calculated using Friedewald formula. Results Smoking prevalence, mean blood pressure and total and LDL cholesterol levels declined markedly during the 25 year follow up but BMI, waist circumference and prevalence of obesity increased (table). CVD risk factor change from 1992 to 2017 Risk factor Men 1992 Men 2017 p value Women 1992 Women 2017 p value Smoking (%) 36.7 20.6 <0.001 25.9 16.5 <0.001 SBP (mmHg) 136.6 131.2 <0.001 130.3 124.5 <0.001 DBP (mmHg) 82.7 81.6 <0.001 78.6 77.8 <0.001 Chol (mmol/L) 5.66 5.17 <0.001 5.42 5.18 <0.001 LDL chol (mmol/L) 3.54 3.16 <0.001 3.26 3.03 <0.001 BMI (kg/m2) 26.2 27.2 <0.001 25.1 26.4 <0.001 WC (cm) 92.8 96.1 <0.001 79.2 86.2 <0.001 Obesity (%) 15.7 23.2 <0.001 14.8 22.7 <0.001 Conclusions The levels of main traditional CVD risk factors have markedly decreased among the Finnish population during the last 25 years but in the same time, obesity has become a major public health challenge.

The North Karelia Project: Cardiovascular disease prevention in Finland.

The extremely high cardiovascular mortality in an eastern province North Karelia in Finland caused great concern among the local population. Action to reduce the problem was demanded in a petition to the Finnish government signed by local representatives of the population. In response, the North Karelia project was launched in 1972 to carry out a comprehensive community based prevention program. After the first five years, prevention activities were also started nationally. The main aim was to reduce the extremely high serum cholesterol, blood pressure and smoking levels with lifestyle changes and improved drug treatment, especially for hypertension. Major declines were seen in serum cholesterol, blood pressure and smoking levels. Coronary mortality reduced in middle age population by 84% from 1972 to 2014. About 2/3 of the mortality decline was explained by risk factor changes and 1/3 by improvement of new treatments developed since 1980s. Population-based prevention through changes in lifestyle and environment is the most cost effective and sustainable way of controlling cardiovascular and other major non-communicable diseases. In the current global situation it is a powerful lesson.

Epidemiologie hypercholesterolemie

Hypercholesterolemia is one of the most important risk factors of cardiovascular (CV) disease. Epidemiology follows the prevalence, the incidence and the possibilities of risk factors or diseases intervention. A review of observation epidemiologic studies, pharmacotherapy and treatment perspectives is presented. The first epidemiologic studies, e.g. the Framingham Heart Study or MRFIT showed hyperlipidemia is associated with the incidence of CV disease. The North Karelia Project showed the intervention of CV risk factors is useful on population-based principles. Interventional studies with statins showed the usefulness of LDL cholesterol lowering to decrease CV morbidity and mortality and also total mortality. Anyway, the control of CV risk factors is unsatisfactory.Key words: epidemiology - hypercholesterolemia - intervention.

Contesting lifestyle risk and gendering coronary candidacy: lay epidemiology of heart disease in Finland in the 1970s.

This study addresses two issues currently under critical discussion in the epidemiology of cardiovascular diseases (CVD), the relative neglect of women and the individualised nature of key risk factors. It focuses on the North Karelia project (NKP), a community programme aimed at coronary heart disease (CHD) prevention in a predominantly rural Finnish region in the early 1970s, that is, during a period when the epidemiological understanding of CVD still was relatively new and actively promoted. Adopting the notions of lay epidemiology and coronary candidacy, culturally mediated explanatory models lay people use to assess who is likely to develop heart disease and why, the study shows that locals targeted by the project critically engaged with both of these bias. Based on the rich materials resulting from project activities the study shows, first, how many locals subsumed the individualised and lifestyle-based approach to CHD prevention promoted by NKP under a more general framework emphasising the health effects of ongoing structural changes in the area, and second, how women constructed themselves as viable coronary candidates. The case supports the position in the current discussions on lay expertise that wants to integrate lay experiences more firmly into epidemiological studies and public health.

Multisectoral approach for promoting public health.

Multisectoral approach (MSA) refers to deliberate collaboration among various stakeholder groups (e.g., government, civil society, and private sector) and sectors (e.g., health, environment, and economy) to jointly achieve a policy outcome. By engaging multiple sectors, partners can leverage knowledge, expertise, reach, and resources, benefiting from their combined and varied strengths as they work toward the shared goal of producing better health outcomes. Improving public health (PH) is challenging because of the size of its population and wide variation in geography. MSA help in addressing identified health issues in focused way as it helps in pooling the resources and formulating the common objectives. One of the major advantages is optimization of usage of resources by avoiding duplication of inputs and activities which tremendously improve program effectiveness and efficiency. Willingness at the leadership and mandate at the policy level are necessary to plan and execute the successful multisectoral coordination. All the major stakeholders require to share the common vision and perspective. Developing institutional mechanism is utmost requirement as it will standardize the processes of intersectoral coordination (ISC). Creation of PH cadre is strategic move to meet the major health challenges being faced by the health system, and it would be anchor of establishing systematic ISC. There are many national and international examples of MSA applications such as for malaria elimination, tobacco control, HIV/AIDS prevention, Finland's community-based cardiovascular disease prevention project (North Karelia Project), and Singapore's Health Promotion Board. Promotion of MSA within the health system and with other ministries is seen as an important measure for effective implementation and improving efficiency.

Why Did North Karelia-Finland Work?: Is it Transferrable?

Successful prevention of cardiovascular diseases in the North Karelia Project and Finland has drawn international attention, particularly as cardiovascular diseases and more generally noncommunicable diseases have become the leading cause of premature mortality in the world. The questions have often been asked about what were the main reasons for success and whether or not the experience could be transferred elsewhere. The main lesson is that the possibilities and potential of cardiovascular prevention are great. The principles of population-based prevention are universal and are expressed in the strategies of World Health Organization. But, the practical implementation of the preventive work must be tailored to local cultural, social, and administrative (political) situations. This paper discusses many elements of the work in North Karelia and Finland that were likely important for success.

Observed changes in cardiovascular risk factors among high-risk middle-aged men who received lifestyle counselling: a 5-year follow-up

Objective: To examine the long-term impact of health counselling among middle-aged men at high risk of CVD.Design: An observational study with a 5-year follow-up.Setting and intervention: All men aged 40 years in Helsinki have been invited to a visit to evaluate CVD risk from 2006 onwards. A modified version of the North Karelia project risk tool (CVD risk score) served to assess the risk. High-risk men received lifestyle counselling based on their individual risk profile in 2006 and were invited to a follow-up visit in 2011.Subjects: Of the 389 originally high-risk men, 159 participated in the follow-up visits in 2011. Based on their follow-up in relation the further risk communication, we divided the participants into three groups: primary health care, occupational health care and no control visits.Main outcome measures: Lifestyle and CVD risk score change.Results: All groups showed improvements in lifestyles. The CVD risk score decreased the most in the group that continued the risk communication visits in their primary health care centre (6.1 to 4.8 [95% CI −1.6 to −0.6]) compared to those who continued risk communication visits in their occupational health care (6.0 to 5.4 [95% CI −1.3 to 0.3]), and to those with no risk communication visits (6.0 to 5.9 [95% CI −0.5 to 0.4]).Conclusions: These findings indicate that individualized lifestyle counselling improves health behaviour and reduces total CVD risk among middle-aged men at high risk of CVD. Sustained improvement in risk factor status requires ongoing risk communication with health care providers.KEY POINTSStudies of short duration have shown that lifestyle changes reduce the risk of cardiovascular disease among high-risk individuals.Sustaining these lifestyle changes and maintaining the lower disease risk attained can prove challenging.Cardiovascular disease (CVD) risk assessment and individualized health counselling for high-risk men, when implemented in primary health care, have the potential to initiate lifestyle changes that support risk reduction.Attaining a sustainable reduction in CVD risk requires a willingness to engage in risk-related communication from both health care providers and the individual at high risk.

Background, Principles, Implementation, and General Experiences of the North Karelia Project.

The extremely high mortality of cardiovascular diseases in the 1960s in Finland, particularly in the Eastern Province of North Karelia and especially that of coronary heart disease in men, caused great concern among the local population. Action to reduce the problem was demanded in a petition signed in 1971 by the representatives of the population. In response, the North Karelia Project was launched in 1972 to carry out a comprehensive preventive project, first only in North Karelia as a national pilot (1972 to 1977), and thereafter continuing in North Karelia but at the same time transferring the experiences to a national level. The intervention was based on the at-that-time relatively new scientific information on the main causal risk factors. A comprehensive population-based intervention was carried out, aiming especially at the reduction of the high levels of serum cholesterol, blood pressure, and tobacco use, emphasizing general dietary changes and smoking reduction. A comprehensive monitoring and evaluation program was designed and implemented to learn from the experience in preparation for national and international use. Presented here are the background, principles, and general experiences of this project, which has made major contributions both to the contemporary public health work for the prevention and control of heart disease and noncommunicable diseases and for research in the area.

From Heart Health to Brain Health: Legacy of the North Karelia Project for Dementia Research.

Cognitive impairment is very common in advanced age, with dementia representing the main cause of disability in older adults. Over the past 20 years, several modifiable risk factors have been identified for dementia and Alzheimer's disease (AD), and many of them are shared with cardiovascular diseases. Given that the pathologic changes leading to dementia may start decades before dementia is diagnosed, it is crucial to adopt a life course approach when investigating risk factors for dementia. The CAIDE (Cardiovascular Risk Factors, Aging and Dementia) study is one of the first and still very few existing observational studies to have investigated the role of midlife risk factors for the subsequent development of dementia and AD in late life. The CAIDE study is built on the North Karelia Project, enabling risk factor assessment 20 to 30 years before the dementia diagnosis. The CAIDE study has revealed that late-life dementia and AD are heterogeneous and multifactorial disorders, suggesting that multidomain interventions targeting several risk factors simultaneously may be needed for optimal preventive effects. The FINGER (Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability) study is the first large long-term multidomain lifestyle intervention showing effect on prevention of cognitive impairment in at-risk elderly people. The study is conducted within the existing framework and builds on multidisciplinary prevention expertise following the North Karelia Project and CAIDE study. The FINGER study will, together with the ongoing multinational preventive initiatives, pave the way for pragmatic prevention programs and integrated interventions to facilitate healthy brain aging. This paper summarizes major findings on risk and protective factors for dementia and AD, and reviews key aspects and future directions in preventative strategies.

40-Year CHD Mortality Trends and the Role ofRisk Factors in Mortality Decline: The North Karelia Project Experience.

In the 1960s and early 1970s, coronary heart disease (CHD) mortality in Finland was the highest in the world, and within Finland, mortality was particularly high in the eastern part of the country. The North Karelia Project, the first large community-based cardiovascular diseases prevention program was established in 1972 to reduce the extremely high CHD mortality through behavioral change and reduction of the main cardiovascular disease risk factors among the whole population of North Karelia, the easternmost province of Finland. During the 40-year period from 1972 to 2012, smoking prevalence, serum total cholesterol, and systolic blood pressure declined markedly, except a small increase in serum cholesterol levels between 2007 and 2012. From the early 1970s to 2012, CHD mortality decreased by 82% (from 643 to 118 per 100,000) among working-age (35 to 64 years) men. Among working-age women, the decline was 84% (from 114 to 17 per 100,000). During the first 10 years, changes in these 3 target risk factors explained nearly all of the observed mortality reduction. Since the mid-1980s, the observed reduction in mortality has been larger than the predicted reduction. In the early 1970s, premature CHD mortality (35 to 74 years) was about 37% higher among Eastern Finnish men and 23% higher among Eastern Finnish women, compared with men and women in Southwestern Finland. During the last 40 years, premature CHD mortality declined markedly in both areas, but the decline was larger in Eastern Finland and the mortality gap between the two areas nearly disappeared.

Tobacco Control: From North Karelia to the National Level.

After World War II, smoking among men was very common in Finland, and especially in North Karelia, contributing to the high rates of cardiovascular diseases and cancer. Thus, the North Karelia Project, from its very start in 1972, took reduction in smoking as one of its main targets. After 1977, the project actively contributed to national tobacco control work, including comprehensive legislation and many other activities. Smoking in North Karelia declined initially much more than in the rest of Finland, but thereafter there has been a steady national decline, resulting in a prevalence of daily smoking among adults of approximately 15% and contributing to the big reduction in the rates of heart disease and tobacco-related cancers, especially among men.

Changes in Serum Cholesterol and Diet in North Karelia and All Finland

Finland in the 1960s, and especially North Karelia in the eastern part of the country, had the highest cardiovascular mortality in the world. The classical cardiovascular risk factors were all common, but serum cholesterol level was extremely high because of the very high intake of saturated fats, mainly from dairy products. The North Karelia Project was started as a comprehensive preventive program to reduce serum cholesterol levels by reducing the intake of saturated fats and increasing the intake of polyunsaturated fats in the whole population. Cross-sectional population surveys were done in North Karelia and nearby Kuopio province every 5 years starting in 1972. After 1982, surveys were started in 2 other areas. Blood cholesterol was measured from serum samples, and diet was assessed by a questionnaire in all surveys-since 1982 by 3-day food record, since 1997 by 24-hour recall, and since 2002 by 48-hour recall. Between 1972 and 2012, the population in North Karelia reduced serum cholesterol from 6.92 mmol/l to 5.46 mmol/l (21%) in men and from 6.81 mmol/l to 5.37 mmol/l (21%) in women. In men, serum cholesterol level reduced more in North Karelia than in the reference province of Kuopio during the first 5 years from 1972 to 1977. Since that time, changes in serum cholesterol level have been very similar in different parts of the country. Saturated fats were reduced from 20% of energy intake to 12% in 2007 but increased from 2007 to 2012 to 14%. In conclusion, serum cholesterol reduction by dietary changes is feasible on the population level but requires active work and large-scale cooperation between all the meaningful sectors in the society.

Blood Pressure, Sodium Intake, and Hypertension Control: Lessons From the North Karelia Project.

From the very beginning of the North Karelia Project, prevention, detection, and control of hypertension were included as key aims in the project. An intensive hypertension prevention and control program was established in North Karelia in 1972 that included community-based activities to reduce blood pressure levels in the entire population, detect people with hypertension, improve their treatment, establish standard diagnostic and therapeutic methods, and to monitor blood pressure levels, control of hypertension, and the performance of the health care. After the first 5 years of the project, most of these activities were also implemented on the national level. In late 1970s, work to reduce the salt intake was started, and substantial reductions have taken place in salt intake in the Finnish population. Remarkable improvements have been seen both in blood pressure levels and in treatment and control of hypertension in North Karelia and in the whole of Finland. Between 1972 and 2012 in North Karelia, the mean systolic blood pressure among 30- to 59-year-old men has decreased from 149 mm Hg to 135 mm Hg and among women from 153 mm Hg to 129 mm Hg. The decreases in mean diastolic blood pressure have been from 92 mm Hg to 84 mm Hg among men and from 92 mm Hg to 79 mm Hg among women.

WHO MONICA Project and its Connections to the North Karelia Project.

The World Health Organization's MONICA (Multinational Monitoring of Trends and Determinants in Cardiovascular Disease) Project was established after the increase in mortality from coronary heart disease had turned to a decline in some countries. Its objective was to measure the trends in cardiovascular mortality and coronary heart disease and cerebrovascular disease morbidity, and to assess the extent to which these trends were related to changes in known risk factors and health care measured at the same time in defined populations in different countries. Thirty-one centers in 21 countries carried out the monitoring over a period of 10 years in the 1980s and 1990s. The project provided information on disease rates, risk factors, and treatment for the first time in most of the study populations. The results answered some of the initial questions and opened new questions on the complexity of the associations between disease trends and their determinants. MONICA had a major impact in training cardiovascular epidemiologists and in creating measurement standards for international use.

Contribution of the North Karelia Project to International Work in CVD and NCD Prevention and Health Promotion.

During the decades after the start of the North Karelia Project in 1971, cardiovascular diseases and related noncommunicable diseases have emerged as the greatest global public health burden. The prevention and control of these diseases have thus become a major challenge and target for global public health, as emphasized by the Political Declaration of the United Nations (UN) General Assembly in 2011. The experiences and results of the North Karelia Project have accordingly received much international attention and have in many ways contributed to the international work in the area, including the strategies and programs of the World Health Organization. The experience of the Project shows the great potential of population-based prevention of cardiovascular diseases and other noncommunicable diseases and that influencing lifestyles related to heart health with comprehensive health promotion and national policies is the cost-effective and sustainable way to improve contemporary public health.

Following in the Footsteps of the North Karelia Project: Prevention of Type 2 Diabetes.

The prevalence as well as actual number of people with type 2 diabetes has been increasing in Finland during the past decades, in parallel with an increase in overweight and obesity. Besides obesity, population aging is among the main drivers of increasing numbers of diabetic patients. Type 2 diabetes brings along complications, most importantly cardiovascular diseases, and increasing type 2 diabetes prevalence has also been suggested to lead to a new upward turn in cardiovascular diseases. Therefore, it is important to implement activities to prevent type 2 diabetes. We present the trial evidence for the prevention of type 2 diabetes with emphasis on the Finnish Diabetes Prevention Study findings. Furthermore, we discuss the practical implementation of screening of individuals for high type 2 diabetes risk and prevention of type 2 diabetes in Finland at the population level and describe how they have contributed to European level initiatives.