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Cholesterol lowering in Karelia

Village competition [1]
Did it work?
Lessons learned

Having the evidence is one thing. Knowing how to implement it is another. With cholesterol we know that getting it lower, for individuals and populations, confers a lower risk of heart disease. The question is how to achieve this.

In Karelia in the 1970s they had one of the highest rates of heart disease in the world, with mean cholesterol levels in men aged 30-59 years of about 7 mmol/L. A lot of effort was put into trying to reduce the high rate of heart disease. One innovative way was to have a competition between small villages to see which one could reduce its average cholesterol most over a two-month period.

Village competition [1]


There were two competitions, in 1991 and 1997. Small villages with populations of 150 to 300 people aged 20-70 years of age. At least 70% had to have an initial cholesterol measured (by finger prick) and at least 80% of these had to have a final cholesterol measured two months later. So there had to be a minimum participation rate of 56%.

Villages had to organise the cholesterol measurements themselves in collaboration with a local heath centre, a heart association and community nurses. Participants had to complete a questionnaire at the end of the competition about changes in dietary habits, risk factors and physical activity. A diet index was calculated ranging from -3 (maximum unhealthy changes) to +3 (maximum healthy changes). The villages also had to organise activities to encourage changes to lifestyle and diet themselves, and there was a prize of about £1,500 for the village with the largest mean percentage decrease in cholesterol.

Did it work?


The results for all the villages in the two competitions are shown in Figure 1. In 1991 seven villages participated with a total population of about 1000. All hit the target 56% participation rate. The mean cholesterol was reduced in six of the seven villages, by a mean of 5.8%. The winning village had a mean cholesterol reduction of 11%.

Figure 1: Mean cholesterol before and after the competition. Each symbol is a village



In 1997 16 villages participated with total population of 2685. Five failed to hit the 56% participation rate. The mean cholesterol reduction in all villages was 9%. The winning village had a mean cholesterol reduction of 16%.

Reduction in cholesterol was associated with changes with fat spread on bread, especially in the 1997 competition with a large increase in stanol use (from 4% to 21%) and a reduction in butter use (from 18% to 10%). The greater change to diet (as measured by the diet index), the greater reduction in cholesterol (Figure 2).

Figure 2: The reduction in cholesterol was greatly influenced by changes in diet



In the best four villages for cholesterol reduction in 1997 there were major changes towards a healthier diet, over and above changes in fat spreads (Table 1). Eating more fruit and vegetables, and eating more fish, confer benefits in addition to those from dietary fat.

Table 1: Changes towards a healthier diet in the best four villages in the 1997 competition

Dietary change Percent
Ate more vegetables 76
Ate less fatty meats 69
Used less cooking fat 69
Changed fat spread on bread 68
Ate more fruit and berries 64
Used less spread 63
Changed cooking fat 63
Ate less full-fat cheese 61
Drank less whole milk 39
Ate less full-fat yoghurt 39
Ate more fish 32

Lessons learned


As expected, the successful villages had organised more self-help groups and activities to inform villagers encourage them to make and sustain changes to their diet. Community activity was both possible and worked, because it harnessed peer pressure for good. In the 1997 competition the largest falls were in housewives, and they were key in informing men about dietary changes.

Of course, this might be fine in a short burst of activity over two months, but long-term changes do not necessarily follow. In the 1997 winning village about two-thirds of the cholesterol reduction had been maintained after a year. And in North Karelia as whole, activities over a quarter of a century have brought the mean cholesterol of men aged 30-59 years down from 7.0 mmol/L to about 5.6 mmol/L, and reduced the number of coronary heart disease deaths by 73%.

Rural Finland is not urban Britain. But there are distinct populations with high risks of heart or other disease, and community awareness and action is one way of achieving change.

References:

  1. P Puska et al. Village competition as an innovative method for lowering population cholesterol. European Heart Journal Supplements 1999 1 Supp S; S64-S72.
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