Search

A hypertension control program was established as part of the more comprehensive North Karelia Project. This project was started in 1972 in response to a petition from the population of North Karelia, a county in Finland, asking for national assistance to reduce the exceptionally high cardiovascular disease mortality and morbidity in the area. The North Karelia Project was carried out from 1972 to 1977.The hypertension control program was implemented mainly in local health centers by physicians and public health nurses, who followed guidelines issued by the project staff and worked under its supervision.Although the target population for the North Karelia Project was the entire population of North Karelia, the project focused on middle-aged men. The hypertension subprogram was introduced in steps. Its objectives included the training of health personnel, establishment of an information system in the county to educate people about hypertension, and organization of the detection, treatment, and followup of hypertensives. A hypertension dispensary was established in each of the 12 health centers in the county. Continuous training of the local public health nurses and physicians faciliated integration of the hypertension program into the operations of the health centers.A central hypertension register and the hypertension control clinics at the health centers were the essential tools in the systematic followup of hypertensives. Some 17,000 hypertensives were on the register by the end of the 5-year project.The main aim in providing health education about hypertension, as well as in treating hypertension itself, was to prevent severe cardiovascular diseases as a whole. Therefore the hypertension control program was integrated into the comprehensive cardiovascular disease control program, and hypertensives received advice concerning smoking and dietary changes as well as about high blood pressure.A survey of health care personnel in North Karelia and in a reference area showed that the care of hypertensives was more systematic in North Karelia and that its health care personnel were more satisfied with the cardiovascular disease care that was provided.

Among the different approaches to the study of cardiovascular disease prevention are community-based programs. This type of program concerns a whole community and the intervention takes advantage of the existing service structure and community organization. The evaluation assesses the feasibility, effects on risk factor and disease reduction, costs, process, and other consequences associated with the program. Several such programs have recently been launched in the United States and some other countries. The first major community-based control program was the North Karelia project in Finland, started in 1972 and recently evaluated for its first five-year period. This paper discusses the problems in evaluating community-based CVD control programs on the experiences obtained in the North Karelia project.

In this study an attempt was made to investigate the application of epidemiological methodology in a cross-national context of studying the variation of coronary mortality. The data on the exposing factors of coronary mortality, the consumption of cigarettes and dairy products, were obtained from OECD statistics, and the data concerning the mortality of coronary heart disease were obtained from World Health Organization statistics. From the correlation and regression analyses performed on the basis of data from 14 countries it appeared that the cross-sectional exposure measurements strongly correlate over decades. For the consumption of cigarettes the time-lag found was from one to two years, while for the consumption of dairy products the respective time-lag was about six to eight years with respect to the effects on the coronary mortality. Because of the small number of observations available the statistical results should not be examined in terms of precise estimates of magnitude but rather in terms of the existence and the direction of relationship between the changes in coronary mortality and the consumption of cigarettes and dairy products. Although the data were insufficient to examine the confounding between the grouping of observations, and length of exposure, they did provide enough information to illustrate the importance of these two methodological aspects in analyses of populations.

We investigated the contribution of risk factor changes to the decline in incidence of ischaemic heart disease between three five-year periods (1972-76, 1977-81, 1982-86) in a community-based cardiovascular disease (CVD) control programme, the nOrth Karelia project. Random population samples of over 10,000 people were examined in 1972, 1977 and 1982 and followed for five years. Population attributable benefits were estimated for each time period from reductions in excess risk associated with S-cholesterol, tobacco products per day and the mean of systolic and diastolic blood pressure which were entered in logistic models with age and sex. Changes in risk factors accounted in North Karelia for 89% and in the reference population for 20% of the decline in ischaemic heart disease from 1972-6 to 1977-81. In healthy people, risk factor reductions accounted in North Karelia for 100%, but in the reference population only for 23% of the decline. The decline was non-significant in both areas from 1977-81 to 1982-86. In subjects with either CVD or diabetes, there was no decline in North Karelia in either period, whereas 30% and 64% of the decline (ns) in the reference population in the two periods, respectively, was attributable to risk factor changes. These data suggest that although the decline in the incidence of ischaemic heart disease in North Karelia did not differ from that in the reference population it was largely attributable to risk factor reductions in the healthy population. The decline in the reference population appears to be associated with changes in lifestyle, secondary prevention activities and medical care.

The antihypertensive, saluretic and hypokalaemic effects of a small dose of cyclothiazide (2.5 mg daily) were compared with those of a conventional dose of an hydrochlorthiazide-amiloride hydrochloride combination (50 + 5 mg daily). Both preparations were given to 13 patients with mild (WHO I) hypertension in a cross-over manner for six weeks, with an intervening wash-out phase of three weeks. The antihypertensive efficacy of cyclothiazide was well comparable to that of the hydrochlorthiazide-amiloride combination, although cyclothiazide tended to inhibit renal sodium reabsorption less than the combination. Cyclothiazide tended to cause hypokalaemia, apparently due to increased potassium loss, but with the present dosage none of the 13 patients developed marked hypokalaemia (serum potassium less than 3.3 mmol/l). Both drugs led to a comparable increase in serum urate concentration. Neither of the preparations affected creatinine or free-water clearance. The results suggest that even in relatively small doses thiazides effectively decrease blood pressure, and combining thiazides with potassium-sparing diuretics is advantageous only in patients with marked hypokalaemia and its associated risks.

A cohort of 1019 male and 1232 female hypertensives, aged 25-59 years, based on a random population sample, was followed for five years during a community-based cardiovascular prevention programme. A small mean reduction in serum cholesterol level was found. The observed changes in casual serum cholesterol values were partly due to the regression to the mean. The reductions were most marked in elderly people and in those with high baseline serum cholesterol values. The partial regressions of the cholesterol change were computed in subgroups by age, sex and baseline serum cholesterol level. Changes in weight in men and in age in women were the strongest independent predictors of the change in serum cholesterol. Changes in dietary fat intake were also associated with the change in serum cholesterol. Only a small part of the total variation in the change in serum cholesterol was explained by the regression models. The results indicate that reduction of the serum cholesterol level among hypertensive persons, especially men, was caused by changes in their dietary habits.

Betaxolol is a cardioselective beta-blocker, which has a bioavailability of 90% and a T 1/2 of 20 h. A four group, cross-over double-blind trial was conducted to select between betaxolol 20 mg and 40 mg for long term trials. 60 patients were allocated randomly to one of the sequences placebo-20 mg, 20 mg-placebo, placebo-40 mg and 40 mg-placebo, each treatment lasting for 2 weeks. Groups were homogenous for baseline diastolic blood pressure (DBP), age and male/female ratio, and were slightly unbalanced for weight. A two-way ANOVA (3 treatments, 2 sequences) showed no treatment-sequence interaction nor sequence effect. The mean reduction in DBP was 14.2 +/- 1.8 mm Hg following 20 mg and 18.0 +/- 1.8 following 40 mg betaxolol, and 4.0 +/- 1.2 mm Hg during placebo (p less than 0.001). Age, weight, baseline DBP and duration of hypertension did not influence the treatment effect. The 95% confidence intervals of the reduction in DBP were 10.4 - 17.9 for 20 mg and 14.3 - 21.6 mm Hg for betaxolol 40 mg. Aiming at a mean reduction to 90 mm Hg, betaxolol 20 mg would appear to be adequate in similar patient populations.

The North Karelia Project - a community-wide health intervention programme - was launched in 1972 as response to the local petition to reduce the heavy toll of heart disease in North Karelia. The strategy of community-based prevention was based on the previous pioneering international work on epidemiology of cardiovascular diseases and prevention in which Finland had in many ways participated. Comprehensive scientific evaluation of the programme was carefully designed. The effects of the programme on risk factor reduction and on prevention of cardiovascular diseases are assessed by large population surveys every five years and by data on incidence of cardiovascular diseases and mortality rates. The authors present the 15 years' results and some of the most recent findings of the North Karelia Project, and discuss the overall experience and its national an international implications.

The relationships of symptoms and blood pressure were studied in a population sample of 1926 individuals. Analysis of covariance showed that none of the 13 symptoms was significantly related to systolic or diastolic BP. Symptoms were more strongly associated with confounding variables.

We assessed the severity of carotid atherosclerosis in 412 men from eastern Finland aged 42, 48, 54 or 60 years at examination with B-mode ultrasonography in 1987 in the Kuopi ischaemic Heart Disease Risk Factor Study (KIHD). Thirty-seven per cent of participants had intimal-medial thickening, 10% had plaques and 2% had stenosis. Age (P less than 0.001), cigarette-years (P less than 0.001), serum LDL cholesterol (P = 0.005), low income (P = 0.020) and low alcohol consumption (P = 0.048) had significant partial associations with the severity of carotid atherosclerosis. A linear regression model including these variables and plasma fibrinogen (NS) and serum HDL-cholesterol (NS) accounted for 33% of the variation in atherosclerosis severity. Our data provide further evidence on the role of smoking and LDL-cholesterol in atherosclerosis.

The use of oral contraceptives (OC) and smoking habits were studied by using a questionnaire in a random population sample of women from two counties of Eastern Finland in 1972. The participation rate was 95%. Data on use of OC and smoking were collected for 2,653 women aged 35-49 years. During the next seven years, 27 of them had developed an acute myocardial infarction (AMI). Smokers had a 2.6-fold (95% confidence interval (CI)=1.2-6.0) crude risk of developing AMI compared with non-smokers. Women taking OC had a 1.3-fold (95% CI = 0.4-6.9) risk of developing AMI compared with those who did not. Women who both smoked and used OC had a 7.2-fold (95% CI = 2.1-24.7) risk of AMI compared with non-smokers and non-users of OC. The results indicate that use of OC is associated with an excessive risk of AMI among female smokers.

The North Karelia Project was a community-based pilot programme in an Eastern Finnish community of 180,000 adults. During the intervention period from 1972 to 1977, the project successfully demonstrated that changing risk factors at the community level was feasible and could result in a significant reduction in disease rates. The North Karelia Project used mass media for dissemination of the message, but relied on face-to-face contact to persuade people to adopt the new lifestyles. Training seminars for professionals were a key programme component. On average, one seminar was conducted every two and a half weeks. Total project costs were only one per cent of the total health services costs for the county during the project. These findings suggest that community programmes can improve both subjective and objective cardiovascular health, and that the strategy of integrating funding into the project recruitment and commitment process is appropriate and may even be necessary for a successful community based heart disease prevention programme.

A community-based programme to improve awareness and control of hypertension was launched in 1972 in North Karelia. It was incorporated in the existing health-services system. An assessment five years later showed that, compared with a reference area not included in the programme, awareness of hypertension had improved, the prevalence of hypertension had dropped, levels of blood-pressure were lower by age-group, and the number of people on antihypertensive treatment had increased.

A total of 532 women with established cervical HPV infection have been prospectively followed (without treatment) since 1981 for a mean of 45 (SD 21) months. The patients were examined by colposcopy, PAP smears and/or punch biopsy every 6 months. The life-table method was applied to analyze the clinical course (i.e. regression and progression) of the HPV lesions, stratified by their colposcopic pattern, PAP smear findings and grade of CIN. During the follow-up, 107 (41.8%) of 256 patients with HPV-NCIN lesion in the first punch biopsy, experienced spontaneous regression. The corresponding proportions for HPV-CIN I, HPV-CIN II and HPV-CIN III lesions were 31.1%, 34.2%, and 20.7%, respectively. In the overall comparison between these four groups, the heterogeneity in the probability of regression was statistically significant (p = 0.0005). Clinical progression was also associated significantly with the histological grade of the lesions in the first biopsy. Progression rate was only 5.8% for HPV-NCIN lesions, as compared to 12.3% for HPV-CIN I, 20% for HPV-CIN II, and 55.2% for HPV-CIN III. The probability of progression varied significantly between the four groups (p less than 0.00001). Cumulative proportion of regression was 46% for patients with PAP smear class I, 84% with class II, and 82% for those with class III, cells, i.e. PAP smear was not of value in predicting the regression. However, PAP smears predicted clinical progression (p = 0.006 overall).(ABSTRACT TRUNCATED AT 250 WORDS)

We investigated the sustained effect of 12-week supplementation of 2.880 g/day of omega-3 fatty acids on platelet aggregability, platelet produced thromboxane B2 concentration and serum fatty acid composition in a double-blind controlled trial in 44 healthy mildly overweight eastern Finnish men recruited from a representative population sample. The supplementation was discontinued seven days before the biochemical measurements. Body weight, alcohol consumption and dietary composition remained constant during the study. Even though the percentage of eicosapentaenoic acid (20:5 omega 3) in total serum lipids increased by 37% (p less than 0.01) and that of dihomo-gamma-linolenic acid (20:3 omega 6) decreased by 18% (p less than 0.01) more in the omega-3 supplemented than placebo group during supplementation, there were no significant differences in the changes in either the ADP induced platelet aggregation or in vitro platelet produced thromboxane B2 concentration between the groups. These data suggest that omega-3 fatty acids have no detectable sustained effect either on ADP induced platelet aggregation or on thromboxane produced by the platelets in vitro.

The study was based on 471 males, aged 19 to 20 years, who started their compulsory military service in three military bases in Southwest, Southeast and Northern Finland in February 1982. Of these subjects 48% smoked regularly and had smoked in the past three weeks. The correlation between the reported number of cigarettes smoked a day and serum thiocyanate was 0.60. Seventy-four per cent of the subjects whose best friend smoked, were current smokers compared with 24% of the others. Proportion of smokers was higher in urban areas than in rural areas. Among the 14 explanatory variables in the multivariate logistic analysis, family members' and friends' smoking, the place of residence, strenuousness of leisure-time physical activities, number of friends, rebelliousness, intelligence test score, and general pessimism were most strongly associated with the likelihood of being a current smoker. The model explained 87% of the smoking variance.

We investigated the association of dietary fatty acids and plasma antioxidative vitamins with blood pressure in 722 eastern Finnish men aged 54 years, examined in the Kuopio Ischaemic Heart Disease Risk Factor Study in 1984-1986, who had no known hypertension nor any cerebrovascular disease. Allowing for the major anthropometric, dietary, medical and psychological determinants of blood pressure in a multivariate regression analysis, plasma ascorbic acid concentration had a moderate, independent inverse association (P less than 0.0001) and the estimated dietary intake of linolenic acid an inverse (P = 0.026) independent association with mean resting blood pressure. The marked elevation of blood pressure at the lowest levels of plasma vitamin C concentration supports the hypothesis of the role of antioxidants in the aetiology of hypertension.

The study was based on 471 men, aged 19 to 20 years, who started their compulsory military service in three military bases in Southwest, Southeast and Northern Finland in February 1982. The data were gathered by means of self-administered questionnaires. A fasting venous blood specimen was taken to determine serum HDL and total cholesterol, gamma-glutamyltransferase and thiocyanate. In this cross-sectional study a few variables based on the self-administered questionnaire explained 8% and 7% of the variation in serum HDL and total cholesterol, respectively. Our results show that easily measurable behavioural factors do contribute to serum HDL and total cholesterol levels in young men. In our study the impact of alcohol consumption on serum HCL cholesterol was greater than in most previous studies. Our findings give additional support to the hypothesis that even a very modest amount of regular physical exercise has the effect of increasing the serum HDL cholesterol level.

In a cross-sectional population study of 1132 unselected Eastern Finnish men aged 54 years, serum selenium concentration had a weak positive association with plasma HDL cholesterol (standardised partial regression coefficient, beta = 0.061, P = 0.019) and a fairly strong inverse relationship (beta = -0.223, P less than 0.001) with the extent of ADP-induced platelet aggregation. Neither plasma ascorbate concentration nor alpha-tocopherol to total cholesterol ratio had any association with plasma lipoproteins, platelet aggregability or prevalent ischaemic heart disease (IHD). When a covariance-correction was applied, men with ischaemic ECG findings at exercise had a lower mean serum selenium than others (81.5 micrograms/l vs. 85.9 micrograms/l, P less than 0.01 for difference). This difference was equally large for men with neither symptoms nor previous diagnosis of IHD.

To assess the effects of bevantolol on stable angina pectoris of effort and its impact on metabolic risk factors, a comparison study of this beta 1-blocking agent and atenolol was undertaken in 40 subjects (mean age 51 years). After a 4-week, single-blind, placebo washout period, 12 men and 8 women were randomized to receive 150 mg of bevantolol twice daily and 12 men and 8 women to treatment with 100 mg of atenolol once daily in a parallel, double-blind, 12-week treatment phase. Patients were assessed at weeks 2, 6 and 12 after bicycle exercise until angina or ST-segment depression greater than or equal to 0.15 mV appeared. Concentrations of cholesterol lipoproteins and 3 prostaglandin metabolites were determined. One patient receiving bevantolol was withdrawn from the study because of insufficient efficacy and 2 receiving atenolol were withdrawn because of side effects. After 2 weeks of therapy, significant decreases were seen in both groups in the number of angina attacks, mean sitting heart rate, systolic and diastolic blood pressure, mean maximum heart rate during exercise and mean double-product of systolic blood pressure and heart rate at the end of exercise. There was a trend toward significance in the increase of mean duration of exercise and total work performed with both agents, although these values were not statistically significant. Both high density lipoproteins and the ratio of high density lipoproteins to low density lipoproteins increased in the bevantolol group and decreased in the atenolol group. These changes were statistically significant at week 6.(ABSTRACT TRUNCATED AT 250 WORDS)

The independent association of serum concentrations of saturated and polyunsaturated fatty acids, apolipoproteins AI and B, selenium and vitamins A and E with the risk of death from coronary artery disease (CAD) was studied in 92 persons with no previous myocardial infarction, who died from CAD during a 5-year follow-up, and their 92 1-to-1 matched controls. Case-control pairs came from a randomly drawn population sample of approximately 12,000 persons aged 30 to 64 years from 2 provinces of eastern Finland, an area with exceptionally high CAD mortality. Control subjects were matched for sex, age, serum cholesterol, mean arterial pressure, tobacco consumption and history of cardiovascular diseases. The persons who died of CAD had lower serum esterified arachidonic acid concentrations before follow-up than the control subjects (41 vs 48 mg/liter, p = 0.05), and this difference was greater for pairs with no chest pain on effort (36 vs 50 mg/liter, p less than 0.05). The adjusted risk of CAD death in persons with a serum polyunsaturated to saturated (P/S) fatty acid ratio of 0.28 or less (in the lowest tertile) was 3.5-fold (95% confidence interval [CI], 1.5 to 8.2) compared with those with higher serum P/s ratios in a multivariate logistic model and 5.6-fold (95% CI 1.6 to 19.8) for pairs with no chest pain on effort. A low serum apolipoprotein AI concentration (1.25 g/liter or less, in the lowest tertile) was associated with a 2.5-fold (95% CI 1.1 to 5.7) adjusted risk of CAD death among the chest pain-free persons.(ABSTRACT TRUNCATED AT 250 WORDS)

A random population sample from Eastern Finland was studied. Altogether approximately 12 000 persons aged 25 to 59 years were examined with participation rate of 92%. Smoking, high saturated fat diet, increased serum cholesterol and elevated blood pressure showed clustering among men but not among women. Smoking tended to cluster in men with high saturated fat intake and hypercholesterolaemia. Increased serum cholesterol clustered with high blood pressure among both men and women. This risk factor clustering may contribute to the exceptionally high coronary heart disease incidence among men in the area. The reverse was true for women: smoking was less prevalent among women with elevated blood pressure or high saturated fat intake and did not differ by serum cholesterol.

Serum high-density lipoprotein (HDL) cholesterol levels were assessed in a random sample of 939 men and 853 women ages 14-65 years in eastern Finland. Amount of daily smoking measured by serum thiocyanate concentration was negatively and independently associated with serum HDL cholesterol level and HDL/total cholesterol ratio in men. This negative association seemed largely to be due to low HDL cholesterol levels in heavy smokers. Both male and female current smokers had lower HDL cholesterol levels and HDL/total cholesterol ratios than those who had never smoked. This difference was found even after adjustment for age, body mass index, and beer drinking. The reduction of HDL cholesterol level seemed to be reversible, because those who had recently stopped smoking had higher HDL cholesterol levels and higher HDL/total cholesterol ratios than current smokers.

The association between oral analgesics and the risk of death from ischaemic heart disease (IHD), cardiovascular disease, disease other than IHD, and any disease was studied in a cohort of 3551 men aged 30-59 years, based on a random sample from the population of eastern Finland. A number of potential coronary risk factors were allowed for in multiple logistic models. On the basis of these data, a regular use of oral analgesics is associated with a decreased risk of death from IHD. The relative risk was 0.6 with 95% confidence interval (CI) of 0.2-0.9 for IHD death and 0.6 (95% CI = 0.4-0.9) for cardiovascular death. No significant association was found between oral analgesics and the risk of death from diseases other than IHD.

We investigated the prevalence of carotid atherosclerosis and its association with serum lipoprotein cholesterol fractions in 412 Eastern Finnish men ages 42, 48, 54, or 60 years who were examined between February and December 1987 in the Kuopio Ischaemic Heart Disease Risk Factor Study. Carotid atherosclerosis was assessed with high-resolution B-mode ultrasonography. Of the participants, 37% had thickening of the intimal or medial layer of the arterial wall, 10% had plaques, 2% had stenosis in the right or left common carotid artery or in the carotid bifurcation, and only 51% were free of any detectable carotid atherosclerosis. The prevalence of atherosclerosis was 14.1%, 32.0%, 67.7%, and 81.9% in the four age groups, respectively. The mean age-adjusted serum low density lipoprotein (LDL) cholesterol concentration was 3.67 mmol/l (142 mg/dl) in men free of carotid atherosclerosis and 4.02 mmol/l (155 mg/dl) in those with at least intimal thickening (p = 0.003 for difference). The mean age-adjusted serum cholesterol concentration in the high density lipoprotein (HDL) fraction was 1.34 mmol/l (52 mg/dl) in the atherosclerosis-free and 1.27 mmol/l (49 mg/dl) in the atherosclerotic men (p = 0.029 for difference). There was a similar difference in both the serum HDL2 and the HDL3 cholesterol levels. Serum LDL and HDL (inverse) cholesterol were significant determinants of severity of carotid atherosclerosis in a multivariate regression model adjusting for age, obesity, plasma fibrinogen, cigarette-years, and duration of hypertension. Our data reveal the high prevalence of atherosclerosis in middle-aged Eastern Finnish men and provide further evidence of the roles of LDL and HDL cholesterol in atherosclerosis.

The interdependence of the associations of physical activity, smoking, and consumption of alcohol and coffee with serum high-density lipoprotein and non-high-density lipoprotein cholesterol concentrations was studied in 9,347 persons ages 25-64 years from east and southwest Finland. In covariance analyses with corrections for age, body mass index, saturated fat index, and fasting time, the mean adjusted serum high-density lipoprotein to non-high-density lipoprotein cholesterol ratio was high among physically active male non-smokers but not among smokers (P = 0.024 for two-way interaction). The cholesterol ratio was lower among both men (P = 0.010 for two-way interaction) and women (P = 0.030 for two-way interaction) reporting no or very little use of alcohol, and this association was stronger among smokers and women with high coffee consumption (P less than 0.001 for two-way interaction). Our data suggest that the elevating effect of regular physical exercise on serum high-density lipoprotein cholesterol may be absent in smokers, whereas that of alcohol is greater in smokers than nonsmokers. High coffee consumption associates with decreased serum high-density lipoprotein cholesterol levels in smokers but increased levels in non-smokers.

Smoking habits are continuously changing in the population. Cessation of smoking is not only often difficult but may lead to undesired consequences, esp. to weight gain. A random sample of 2283 persons with mild hypertension was followed up for 5 years in Eastern Finland and examined at the community-based cardiovascular program. During that time 30% of those smoking initially stopped smoking. Men gained weight on the average 3.6 kg upon stopping smoking (p less than 0.001) after controlling for age, change in fat and sugar intake and change in physical activity at leisure time). In women cessation of smoking was not related to weight changes. There was no evidence in this follow-up that smoking or cessation of smoking would have any independent impact on blood pressure or serum total cholesterol level.

Ecological between-area comparisons, hospital-based case-control studies and cross-sectional angiography studies have provided data on the role of selenium (Se) deficiency in the aetiology of ischaemic heart disease (IHD), but this evidence is, at best, suggestive because of the potential selection biases and the lack of certainty of the temporal direction of the observed associations. Out of the four cohort-based population studies published so far, one observed a moderate association between a reduced serum Se and an increased risk of IHD and all cardiovascular (CVD) deaths, one was equivocal and two did not find any association between serum Se and IHD. There are, however, several potential sources of biases acting towards the null hypothesis in these studies. In the pooled data of the two separate cohorts from eastern Finland including 377 people who experienced a CVD death or a non-fatal myocardial infarction and equally many event-free risk-factor matched controls, people with serum Se of less than 45 micrograms/l had a 1.7-fold (95% confidence interval 1.2-2.7) risk of an CVD event compared to those with higher serum Se. This association could, however, be explained by the covariation of Se with other nutrients, as for example n-3 polyunsaturated fatty acids. As the evidence concerning the role of serum Se in IHD is inconclusive, we need new epidemiological studies to test the association and experiments exploring the possible mechanisms.

In 1972 a cardiovascular disease prevention programme was started in North Karelia in Eastern Finland. At the outset of the programme a random sample comprising 10940 persons aged 25 to 59 years was studied. Those subjects whose systolic blood pressure was greater than or equal to 175 and/or diastolic greater than or equal to 100 mmHg or who were undergoing antihypertensive treatment, were re-examined in 1977. Their body weight was measured both in 1972 and 1977. The changes in their physical activity, smoking and eating habits were also interviewed. The men aged 25 to 49 years had increased their body mass index by 0.4 kg/m2 and the men aged 50 to 59 years by 0.2 kg/m2, on average. In women (aged 25 to 49 years) body mass index had increased by 0.5 kg/m2 but decreased in the age group 50 to 59 years by 0.2 kg/m2, on average. In men the change in body weight exerted the strongest partial regression on the change in smoking, age and physical activity (both in leisure time and at work). In women aged 25 to 49 years the reasons for increased body weight were the same as in men. In older women, aged 50 to 59 years the decrease in body weight was associated with age, change in amount of smoking and initiation of antihypertensive drug therapy.

In a large, community-based cardiovascular disease prevention study in Eastern Finland, independent random population samples were surveyed in 1972, 1977 and 1982. The leisure-time physical activity (LTPA), occupational physical activity (OPA), and socioeconomic and lifestyle characteristics were assessed. In men and women aged 30-59, the proportion with high LTPA increased from 1972 to 1982 by approximately one half (p less than 0.001), whereas that of high OPA decreased during the same period (p less than 0.001). In both sexes, high overall physical activity fell from 1972 to 1977 (p less than 0.001), but no more from 1977 to 1982. The proportion of entirely sedentary remained stable. Education, income and younger age showed a positive, body mass index, smoking and OPA a graded, negative association with high LTPA in 1972 and 1982. Significant (p less than 0.001) differences in 10-year trends of changes in LTPA were observed: men and women with low education or income increased LTPA more than those with high education and income. Socioeconomic factors, such as income and education, appear to have lost importance as determinants of population-wide exercise, whereas the clustering of low physical activity with overweight and smoking has increased.

Risk factors for coronary heart disease (CHD) and levels of leisure-time physical activity (LTPA) were measured in a random sample of 4,059 women aged 25-64 years, residing in four areas of Finland. LTPA indexed as the product of weekly exercise sessions X their usual intensity showed an inverse association with smoking (p = 0.02) and with CHD risk estimate which combines the three main risk factors, smoking, serum cholesterol and blood pressure (p = 0.06), and a positive association with HDL cholesterol (p = 0.002). It was not associated with mean arterial pressure and serum total cholesterol. In a multiple regression analysis LTPA contributed independently, though modestly, to the model for CHD risk estimate. Age and body mass index were the most important independent predictors of both mean arterial pressure and CHD risk estimate. It is concluded that in middle-aged Finnish women, unlike men of the same population, high LTPA is only weakly related to lower CHD risk factor levels.

The association of self-reported use of alcohol with blood pressure and compliance with antihypertensive medication was studied in a randomly selected population sample in eastern Finland. We found a positive correlation between reported use of alcohol and diastolic blood pressure level and a negative correlation with the reduction of diastolic blood pressure during a five-year treatment. These correlations were independent of age, gender, and blood pressure level 5 years earlier. The use of alcohol was associated, especially in men, with poor compliance with antihypertensive medication. In addition to a possible direct contribution to high blood pressure, alcohol intake resulted in an inadequate control of blood pressure in male hypertensive patients by lowering patient compliance.

Body mass index (weight (kg) divided by height squared (m2] and its association with the risk of myocardial infarction and death from all causes were studied prospectively in a randomly selected population sample in eastern Finland aged 30-59 at outset in 1972. The study population consisted of 3786 men and 4120 women. The participation rate in the survey in 1972 was over 90%. All deaths and admissions to hospital in the sample were obtained from the National Death Certificate and Hospital Discharge Registers. During the seven years of follow up until 1978, 170 men and 52 women had acute myocardial infarction, and during the nine years up to 1980, 223 men and 92 women died. Independent of age, men with a body mass index of 28.5 or more had a significantly higher incidence of acute myocardial infarction. This effect was also independent of smoking but not independent of biological coronary risk factors--that is, serum cholesterol concentration and blood pressure. In the analysis stratified for smoking in men the body mass index total mortality curve was J shaped among non-smokers, whereas smoking entirely outweighed body mass index as a predictor of death. Body mass index did not contribute significantly to the risk of either acute myocardial infarction or death in women. It is concluded that a body mass index of around 29.0-31.0 or more is not only a marker for coronary risk factors but is also a predictor of acute myocardial infarction in men.

A marked increase in the coronary heart disease (CHD) mortality of working-age men and women occurred in Finland from the 1950s until the 1960s. Around the year 1970, CHD mortality started to decline and this decline still continues. In the age group 35-64 years the average annual decline of CHD mortality in the 1970s was 1.8% for men and 3.4% for women. Limited data available on trends in CHD morbidity show that the decline in CHD mortality is accompanied by a decline in the incidence of non-fatal myocardial infarction. CHD mortality and incidence are higher in east Finland than in west Finland and this east-west difference has so far persisted during the declining trend. The decline in CHD mortality and incidence in the 1970s has been preceded and paralleled by changes into favourable direction in dietary fat consumption and population mean levels for serum cholesterol, prevalence of smoking among adult Finnish men, control of hypertension by antihypertensive drug therapy, and management of patients with symptomatic CHD. Both the changes in life-styles and CHD risk factor levels, as well as changes in the management of patients with CHD, appear to have been contributing to the decline in CHD mortality and incidence in Finland.

There has been a general decline in mortality from ischaemic heart disease (IHD) in Finland since the beginning of the 1970s. An intensified preventive programme was started in the province of North Karelia in 1972. Between 1974 and 1979 the decline in IHD mortality in North Karelian men was steeper than that in the rest of Finland. This favourable trend was associated with a fall in the levels of major coronary disease risk factors. Case-fatality from acute coronary events did not change much during this period. A levelling off in the decline in IHD mortality has been observed in the 1980s first in North Karelia and later in the whole of Finland. These findings from the official mortality statistics were confirmed in North Karelia by the data from the population-based coronary register. This levelling off in the decline in IHD mortality was associated with levelling off in risk-factor reductions in eastern Finland and with little improvement in risk-related behaviours in Finland during the 1980s. The IHD rates are still high and associated with persistent high risk factor levels and particularly with high serum cholesterol and blood pressure levels. Together with IHD mortality, the decline in total mortality also levelled off both in North Karelia and in the rest of Finland during the early 1980s. Compared with other countries, the rates of coronary disease and total mortality in the middle-aged Finnish population, especially among men, are among the highest in the world.(ABSTRACT TRUNCATED AT 250 WORDS)

We investigated the association of dietary fatty acids and antioxidants with blood pressure in 722 eastern Finnish men aged 54 y, examined in the Kuopio Ischaemic Heart Disease Risk Factor Study in 1984-86. Men with self-reported hypertension or cerebrovascular disease or under antihypertensive medication were excluded. Allowing for the major anthropometric, dietary, medical, and psychological determinants of blood pressure in multivariate regression analyses, both plasma ascorbic acid (p = 0.0008) and serum selenium (p = 0.0017) concentrations had a moderate, independent inverse association, estimated dietary intake of saturated fatty acids had a positive association (p = 0.013), and estimated dietary intake of linolenic acid had an inverse (p = 0.048) association with the mean resting blood pressure. The marked elevation of blood pressure at the lowest levels of plasma ascorbic acid and serum Se concentrations supports the hypothesis that antioxidants play a role in the etiology of hypertension.