June/July 2006

Seppo Holttinen loved to dance. He met his wife on the dance floor. He boogied with his kids. And on September 21, 1976, the forestry engineer danced with friends after a company meeting in the capital city of Joensuu, in Finland’s rugged easternmost province of North Karelia.

It would be the last time. The 38-year-old blond-haired, blue-eyed, slim, handsome Finnish father of three collapsed on the floor with his third heart attack and died soon after at the hospital. Just one month earlier, his own father had died of a heart attack.

While it might seem shocking, in 1970s North Karelia, Seppo Holttinen’s death was nothing short of ordinary. “Heart disease was so common back then,” said Vesa Korpelainen, executive manager of the North Karelian Center for Public Health. “When people were asked, ‘Do you have coronary disease?’ a very common answer was, ‘Not yet.”’ Finnish men had the world’s highest rate of heart disease mortality, and North Karelia’s rate was 40 percent worse than that-even in a region where most men held physically active jobs like logging and farming.

Finns in the 1970s enjoyed butter, whole milk, sausage, salt and cigarettes. Fruits and vegetables were rarely on their menus; for example, by the time Korpelainen did military service at age 20, the only vegetables he had ever eaten – perhaps ten times in his life – were tomatoes and cucumbers.

But by the early 2000s, the number of deaths of working-age Finnish men from coronary heart disease had plummeted 75 percent. In North Karelia, the number was even better – 82 percent and life expectancy for every man went up 7 years. Much of this reduction in mortality came from dramatic reductions in risk factors like high blood pressure, high cholesterol and smoking. In less than two generations, the Finnish lifestyle became the envy of the world.

What happened?

In 1972, a program called the North Karelia Project radically adjusted the habits of a whole community of Finns and, eventually, the entire Finnish population. “It was a question of general lifestyle of the community-not just some people with high risk factors,” said Pekka Puska, M.D., Ph.D., the public health physician who directed the project. “The whole environment had to change-the food industry, restaurants, cafeterias, supermarkets.”

In other words, Puska and his team made sure that healthy choices became easy choices for every person in the province. And to do it, they had to fundamentally change society itself.

Battling Butter, Salt, and Smokes
World War II was a difficult time in North Karelia. The Soviets attacked in 1939, taking part of the province in what came to be called the “Winter War.” Many people came close to starving during the war, so when the fighting ended in 1945, people celebrated. “They started drinking fatty milk, they ate a lot of butter, pork and fatty meat, cream, and, of course, also started smoking a lot of cigarettes, which they now could afford,” said Puska.

The price for such celebration, however, was steep: cardiovascular disease for working men skyrocketed to the world’s highest levels. A thousand heart attacks occurred each year in North Karelia, a region of only 180,000 people. Half of those struck men younger than 65, and 40 percent were fatal. One tenth of North Karelian men and women between the ages of 45 and 59 were on disability leave due to heart disease.

After years of suffering, the citizens of North Karelia finally petitioned the national government for help in 1971. Something – they didn’t know what – needed to happen to stop their young men from dying.

Enter Pekka Puska. Then a 27-year-old doctor with a master’s degree in social science, Puska had been president of the national students’ union and had come of age during a time of unrest in universities all over Europe. He believed entrenched systems could be changed, and quickly became the government’s choice to head up an ambitious program to help North Karelia. Studies had linked certain risk factors to increased heart disease, but it was not yet known whether reducing them would actually stop people from dying. Puska, now the Director General of Finland’s National Public Health Institute, decided that the only way to attack such a systemic problem was a multi-pronged approach, addressing the environment, culture and economy of the entire 180,000 – person province of North Karelia.

Homemakers Carry the Torch
Puska and his team had three goals: reduce cholesterol, lower hypertension and cut smoking rates. To accomplish this they began on the ground. They handed out pamphlets at supermarkets with heart-healthy eating suggestions and tips for stopping smoking. They spoke at town meetings. They visited health centers and schools. Their message, however, was not well received. “It was horrible when they told us we had to drink skim milk and use margarine, and eat fruits and vegetables,” said Jukka Holttinen, Seppo Holttinen’s son, now a 40-year-old teacher with two children of his own.

Especially controversial for people of this dairy-farm-dotted region was the doctors’ advice that they switch from butter to vegetable oils and margarine (this was the pre-trans-fat era, and margarine’s luster as a healthy food had yet to be diminished). “There was quite a lot of discussion that we were fighting against farmers,” said Aulikki Nissinen, a doctor who worked on the project from the beginning.

“If you had a few cows of your own, convincing you to switch from something you produce yourself to buying some kind of imported vegetable oil was really difficult,” added Puska. Because of the Nordic climate, fruits and vegetables – which usually had to be imported – faced the same resistance.

So the team went in “boots deep in the mud,” as Puska describes it. The North Karelia Project joined forces with the Martha Organization – a national housewives group (similar to 4-H) devoted to educating its members about nutrition, kitchen efficiency and household budgeting (named after the biblical Martha, Lazarus’s sister, who was “busy everywhere,” says Nissinen). Together, the two groups took on traditional, fat-filled recipes and gave them a healthier spin; even the beloved Karelian Stew, a melange of butter-browned meats simmered in heavily salted water, was remade with added rutabagas and reduced sodium. They sponsored over 300 “Parties of Long Life,” where the women gathered on Sundays with their families at schools or community centers to try out the new recipes and listen to medical lectures by Puska and his colleagues. By keeping the pressure on in Finnish homes, the Marthas “were our best allies,” said Puska.

At every turn, Puska and his colleagues used positive reinforcement. When worksites lowered the salt in their cafeteria menus, for example, the cooks would pile the unused salt in huge glass jars for all employees to see. There was drama, too: towns were pitted against each other in cholesterol-lowering competitions. “People went to each other’s homes, looked in each other’s refrigerators, to see whether they had vegetables or butter inside,” said Puska. The winning towns received cash prizes, earmarked for programs like bike paths and walkways.

And, in what may have been the world’s first reality-TV show, Puska’s group appeared regularly on a program that followed eight to ten high-risk people for weeks as health experts counseled them how to quit smoking and give up other unhealthy habits. Between one-quarter to half of the country watched the show during any given season in its 13 year run. It inspired many: over a quarter of male viewers reduced their fat intake.

The Message Spreads
After just five years, the North Karelia Project went national.

Its success, says at least one international observer, was due to the Finnish outlook on life. “The Finns have a very pragmatic nonideological approach to life in general,” said Derek Yach, physician and director of the Rockefeller Foundation’s program on global health and a former World Health Organization colleague of Puska’s. “They see a problem and they don’t have a big long debate about what’s the philosophical reason or individual responsibility. They recognized that these lumberjacks were dropping dead and that it was because their food was not optimal.”

Aside from the original, local initiative, Puska and his group were also urging legislative change from the top down. Food labeling laws were changed, first in North Karelia and then nationally, to mandate clearer labeling for low-fat and low-salt foods to make them easier for consumers to find. The national school-lunch program also got a major overhaul: butter on school bread (the biggest source of fat in kids’ diets, since Finns traditionally eat buttered bread at almost every meal) was replaced by margarine. Whole milk was switched to skim milk or water, and cafeteria staff pushed fish, poultry, vegetables and salads. The manufacturers who supplied the food were encouraged to lower salt levels and use salt substitutes.

Also targeted were dairy subsidies, which rewarded cream and butter production and taxed margarine so that it cost as much as butter. There was, unsurprisingly, plenty of resistance, since dairy farms were ubiquitous in Finland. But after continuous pressure from Puska’s team-and the subsequent lowering in the consumer demand for butter as a result of their work the subsidies were eventually dropped, opening the door for margarine and vegetable oils to compete.

The farmers, however, were offered trade-offs. When scientists developed a type of rapeseed plant that grew well in the northern climate, the project encouraged farmers to replace their lost revenue with the plant, to make their oil – canola – a national product that could viably replace butter. They also reawakened enthusiasm for growing local berries – a longtime Finnish forest tradition that had fallen by the wayside. Today Aulikki Nissinen, one of the project’s founding team members, picks 50 gallons of berries every summer and freezes them to use all year; so do many of her neighbors.

Puska’s team also worked with bread companies, urging them to lower the salt and replace butter in their recipes with vegetable oil. They took on sausage makers, too, suggesting substituting mushrooms for some of the pork, for example, and cutting salt. “The sausage industry said in the beginning they couldn’t make the sausage with lower salt,” recalled Nissinen. “Somehow they managed it when people started to demand it.” Now, all the major sausage companies are “working with health,” said Puska. “If you go to a supermarket here, you see lots of low-fat, low cholesterol meat products.”

But it was not simply changes in laws and regulations that made the difference, according to Derek Yach. “It was actually that discourse surrounding a proposed law that made the biggest difference, not the law,” he noted. “That’s quite exciting news, because it means that the more you can have an open media debate around changing lifestyles…the more likely you are to achieve sustainable outcomes.”

Fitness for all Finns
But diet is just one part of lifestyle. The project soon set out to address another part: physical activity. In fact, back in the 1970s, North Karelia’s lumberjacks and farmers worked hard and, despite their diets, were quite slim. But over time, people left those jobs for more sedentary ones. The long, dark Finnish winter, with its inevitable snow and ice, didn’t make things any easier.

So the project team worked with local governments to make it easier for Finns to be active in any weather. They made sure walking paths were clear and gave out free tractioned shoe clamps to the elderly so they could walk in the winter. They increased the number of miles of bike paths and created well-lit, safe cross country ski parks. “Every municipality, every village has tracks for skiing. Here in Joensuu we have hundreds of kilometers,” said Vesa Korpelainen. In effect, Finnish cities became free, convenient outdoor gyms. As with other Scandinavian cities, “they tend to be smaller, highly walkable and pedestrianized,” said the Rockefeller Foundation’s Yach.

In 1980, Finland passed the Sports Act, obligating central and local governments to provide facilities for their citizens to get exercise – tracks, pools, ice rinks and sports halls. Now, the ratio of sports facilities to people is one of the highest in the world. In all, Puska and his team created a system in which every aspect of people’s lives nudged them toward healthy choices and away from unhealthy ones. They did this by removing barriers, making it fun and using social events. They gave people control of their health by helping them monitor their progress and then showing them—and celebrating—positive results. And it worked.

Total blood cholesterol declined 18 percent in both North Karelian men and women from 1972 to 1997; for most, a healthier lifestyle is now almost a routine. Almost no one drank low-fat milk in 1972. Now, nearly half of all women and 40 percent of men drink skim or 1 percent milk. While 90 percent of people buttered their bread in 1972, only 10 percent of people do now. More than a third of the country uses vegetable oil rather than butter for cooking, up from just 1 percent back then.

On the exercise front, an estimated 65 percent of Finns are regularly active, Puska notes. The latest craze, among all ages, is called Nordic walking—basically, walking with sticks in a summer version of cross-country skiing. Nearly one in five Finns Nordic-walk at least once a week.

Kids approve of the healthy, free school lunch. “We have different kinds of salads, we always have bread. People drink skim milk, water or juice. And we have different foods for vegetarians. And yeah. I like our school food,” said Maija Naumanen, a 17-year-old high school student in Joensuu, North Karelia.

Most heartening, perhaps, is how cost-effective programs like the North Karelia Project were. During the height of its efforts, from 1971 to 1979, the project spent just $1.75 million total (about $4.8 million in today’s dollars), reported Puska. This figure is low partly because the project used existing infrastructure, working to make health care and university resources more effective. Even so, the reduced numbers of heart attacks and strokes saved the country an estimated $2 million (about $5.5 million today), and the reduction in disability pensions saved another $4 million (now, $10.9 million). That doesn’t count, of course, the incalculable: families spared the loss of loved ones.

The Struggle Continues
The work in Finland wasn’t perfect, and isn’t done yet. It took—and is still taking—day after day of constant work and incessant reminders. Social problems continue to grow, including alcoholism; per-capita alcohol consumption has doubled in the last 30 years. Fast food and video games have invaded. An emerging health concern is “saturated fat from cheese or fast foods,” Puska said. “You continuously have to push.”

Finland does enjoy a few advantages other countries lack. “It’s a relatively small country with only about 5 million people—Pekka Puska and his colleagues are still grounded in the communities, yet can get on the phone to the prime minister and say, ‘You still aren’t doing enough,’” said Rockefeller’s Derek Yach.

But that doesn’t mean its success is limited to similarly small countries. Local governments—cities and states—can have strong impacts, even more powerful if supported by the federal government. Individuals can also make changes, but it’s a tough uphill battle only people with enough money, time and mental health can afford to fight. Or, as Yach has written, “individual responsibility can have its full effect only in a society where governments, private interests and other sectors work together to support individuals making healthy choices.”

Puska agrees—and believes the lessons of North Karelia can be used everywhere, as they have in countries as diverse as Iran, Canada and even the United States. “High blood pressure kills everywhere, high cholesterol kills everywhere. Even if the actual situations look very different—a Boston suburb or Africa—human behavior is pretty universal,” said Puska. Healthy choices need to be easy choices, and when they are, people make them.

Jukka Holttinen makes good choices, though these choices were unheard of in 1972. “I drink skim milk, eat fruits and vegetables and salads. We don’t use so much salt as back then,” he said. “I do not smoke—my father smoked—and I also exercise every day.” At age 40, he’s two years older than his father was when he collapsed on the dance floor 30 years ago. Jukka has worked to stop the cycle, but he has had help: healthy choices in the supermarket, cheap, ubiquitous exercise facilities and a community of people of a similar mind have all nudged him in the right direction. He is hoping that his kids will have him around to nudge for many more years to come.

SIDEBAR
Could it happen here?
In many respects, the U.S. is facing a crossroads something like the one that challenged Finland 30-odd years ago, with an ever-growing, seemingly intractable obesity epidemic. Would a Finland-style, full-barreled approach to changing lifestyle-related health issues work here?

“The obesity problem has not been solved anywhere in the world, including Finland,” said Derek Yach, director of the Rockefeller Foundation’s program on global health. “However tough it was to bring down the cardiovascular-disease rates, obesity is going to be much more complex.”

First off, the basic structure of our society makes physical activity difficult. Since the post-World War II economic boom, most U.S. communities have been planned around automobiles, so for most of us, any activity—going to school, work, shopping—means getting into a car. And the food that’s cheap and ubiquitous tends to be the most unhealthy. “For a low-to-middle-income person to go to McDonald’s and have an energy-dense bunch of hamburgers and fries is an economically sensible choice in that family,” said Yach. “It’s a tougher choice for them to go and find fruits and vegetables and a balanced diet the way we would prefer them to eat.”

And while Finns can expect their national institutions to take on these challenges, we have a different philosophy about government’s role in public health. “I don’t think there will be a reliance on government to help,” said Mark Dessauer, communications director of Active Living by Design (ALbD), a national program that promotes routine physical activity through community design. “The American character is to believe in individual rights.”

While certainly not on the scale of Finland, America is starting to fight obesity on myriad levels, public and private. You see proof every time states pass laws to restrict vending machines in schools or when health-insurance companies give discounts for fitness-club attendance. ALbD is itself a force for change: backed by the health-care philanthropy giant Robert Wood Johnson Foundation, it funds 25 partnerships across the country to help make communities more supportive of physical activity, including some highlighted in these pages.

Dessauer believes solutions will come not with one big national push, but with many grassroots efforts like the ones ALbD supports. Though federal or state funding for such initiatives is important, the major supports are likely to be private: “It’s going to come from insurance companies, HMOs, corporations that want to be good citizens.” Workplaces will be involved, too, he added, as rising health-care costs compel them to help their workers live better. “General Motors now pays more for health care than for steel.”

For his part, Yach sees opportunity: the U.S., facing one of the world’s highest obesity rates, could lead the way in “triggering the societal changes that will start bringing the epidemic down.” He added, “I do think the U.S., when they finally turn their mind to it, will become a world leader in getting it right.” (Sidebar by both Rachael Moeller Gorman and Joyce Hendley)

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