SPECIAL REPORTS

Miracle Up North

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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.”

Illustration by Joshua Highter

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.
—By Rachael Moeller Gorman
—Illustration by Fred Lynch

Transformations USA
HOPKINS, MINNESOTA: School lunch gets a makeover, from scratch

Stop by the “Tuscan Oven” for Chicken Cacciatore with Braised Greens, pick a freshly stir-fried Pad Thai at “Ethnic Adventure” or dig into Fennel-Crusted Pork Loin with Gravy at “Kremer’s Diner”: it would be the food court of your dreams, were it not the Hopkins High School cafeteria. Like all the public schools in this district just west of Minneapolis, HHS is served by a revolutionary food-service program, “Royal Cuisine,” that aims to not only meet the USDA National School Lunch Program’s guidelines for healthy school fare, but to exceed them, deliciously.

While other regional schools serve an endless litany of reheated packaged nuggets and dunkers, Royal Cuisine’s mission is to offer foods that are “fresh, of high quality and minimally processed,” with over 80 percent of its meals made from scratch, according to Royal Cuisine’s innovative director of operations, Bertrand Weber. The pizza is made with a whole-wheat crust, the green beans are freshly steamed, not canned, and the milk is organic. Even the à la carte items like chips and drinks are free of trans fats and high-fructose corn syrup. The district’s “Farm to School” program promotes regional produce—most recently, asparagus and strawberries—and the farmers who grow it.

Weber views school lunch as a learning opportunity. “Kids live in a society that inundates them with nothing but fast food and processed foods—just look at what’s on the kids’ menus at restaurants,” he explains. “We’re not so much
introducing them to ‘new’ foods, but to normal foods.” And, while burgers, fries and chicken nuggets do make an appearance, they’re downsized: “We only serve those kinds of foods once or twice a month, and we present them in moderation.”

Keeping costs down is a challenge, with about 20 percent of the district’s kids qualifying for free or reduced-price meals. As other public schools must, Weber pinches pennies by supplementing his menus with USDA commodity foods—but chooses raw ingredients like flour and cheese rather than prepared items. Royal Cuisine also brings in income by running a catering service, and is exploring a concept of selling grab-and-go family dinners. And, while the district charges slightly more for meals than others in the region—a high school lunch, for example, is $2.75; in nearby Minneapolis it’s $2.00—kids and parents have voted their approval with their forks. Since Weber came on board in 2003, lunch sales at the high school have nearly doubled.
—Joyce Hendley

COLUMBIA, MISSOURI: A community builds for biking and walking

For some time now, the University of Missouri’s hometown has been known as a haven for bikers and walkers. But we haven’t seen the half of it yet.

The "walking school bus" project

“We’re building a bike and pedestrian infrastructure,” explains Ian Thomas, executive director of the PedNet Coalition, a partnership of active-living advocacy groups. PedNet envisions sidewalks, bicycle lanes and trails that connect the “hub” of downtown Columbia with 10 major “spokes”—routes that feed outward to the town’s edges. Soon, commuting to work by bike or on foot will be not only possible, but easy: last year, Columbia was one of four cities chosen to receive a $25 million grant from the Federal Highway Administration to improve these nonmotorized transportation options. “It’s a dream come true,” says Thomas.

And it’s not just grown-up commuters who now have more choices. Children at five area schools participate in one of the nation’s most ambitious “Walking School Bus” programs: volunteer “drivers” help kids get to and from school en masse and on foot—building safe, fun activity into their school days. Thanks to PedNet’s advocacy efforts, a $3.5 million street-improvement package is upgrading sidewalks around schools to make those school routes safer and easier.

PedNet, funded by a grant from Active Living by Design (see “Could It Happen Here?” page 37), also sponsors “Bike, Walk, and Wheel Week,” which drew 1,700 bikers, skaters and walkers last year to try a nonmotorized form of transport on for size. Area restaurants offered free breakfasts to anyone commuting car-lessly—which proved a major draw. “People say, ‘I’ll try it and get my free breakfast,’ then they find out it wasn’t as hard as they expected,” notes Thomas. “That certainly happened with my wife, who now commutes to work on her bike most days.”
—Joyce Hendley

UPPER VALLEY, VERMONT/NEW HAMPSHIRE: Take 2 miles and call me in the morning

Come to Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire, for a checkup and you might go home with a prescription for exercise—and a map of local walking/biking trails. “Relatively modest weight loss and an increase in exercise—30 minutes of brisk walking a day—has health benefits equal to or superior to a pill or a procedure,” noted Charles Brackett, M.D., a Dartmouth-Hitchcock physician who coordinates the “Trails for Life” program with the Upper Valley Trails Alliance (UVTA), a consortium whose goal is to help area residents become more active.

The UVTA works to ensure there are plenty of places to walk and bike—a tall order in this woodsy region famed for its long winters. A recent achievement is the Lake Morey Ice Trail, a two-mile, groomed ice path that lures skaters to use it as a winter equivalent to walking and hiking.

Funded by members, local businesses and a grant from Active Living by Design (see “Could It Happen Here?” page 37), UVTA sponsors annual “Bike/Walk to Work” days and a “Passport to Winter Fun” event to get families out of hibernation and onto skis and skates. “Our weather doesn’t have to be a barrier,” says UVTA executive director Wally Elton. “I know a guy with studded tires on his bike.”
—Joyce Hendley

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.”
—By Rachael Moeller Gorman and Joyce Hendley

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