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DISCUSSION Ickh•. It is pre• ^tne smoking. of treating hypertension, and of will slow the -educing dietarv saturated fat, the level of risk fac- -seed policies. :nrs among the "usual care" half fell much beyond :::.It protected by the study designers. As a result, lcrmal. 2: 1525 nnlc 104 coronary deaths occurred, not sigrttfr- ..L.n.a pl rfl7arM!- -q), 48: 1aG5 (198:). 6 m~i;cal~e>,rr.r.: ,;rneva. 1Corld . ,kt Report 6-b). 10: :1? (19'G). ••.arrrer. Loudon. .crs. 1981. tion ~ multiple risk zor his argu• re n%k factors vcn up. •hoa• lust the aonahtt were i gtven special to their usual rs of the study •t; the "usual .L, preserving ronarV deaths :ulated that a rs among the reduce their to 137, thus :Id be statisti• It risk factor )ltver's Inter• nd thetr rhy • .ituc (7f stop• .nal Medicme 3t School. Dal. -amlr more than the 92 among the "speelal inter- ,uluwrt• Thus. coronary mortality was markedly reduced :n 7oth groups, u•ith a reduction in thti various risk crors mcasured in both groups. Obviously, the dcsi¢n of Fhe study was flawed so that it failed to >!to.v a diEiercncc m mortality, but bc no means tices this lack of difference between the two groups •lentir a lack of efticacr of risk factor intervention. Tite tria) failed in flts oriFinal purpose but it suc- cccded admirably in demcnstrat:ng the value of risk Ictor reduction. Though I agree w'ith Oliver's call for selectivity in applrirtg interventions that may have some Pekka Puska, Jukka T. Saln- aen, Jaakk© Tuomilehto, Au- lin, & Kaj Koskela iilcki Nissino - We have good reason to promote general risk factor reductions in whole populatiodns Professor Oliver's reference to the North Karelia prole.t merits comr$tent since our conclusions dif- fer from his. At 6ve Fears (1, 2) a reduction in risk factor levels was indeed noted. During this period coronan• heart disease rates did start to decrease in North l:arelia (in contraoiction to Oliver's state- ment), but no significant difference could then be observed in coronary heart disease mottalit)• trends between North Karelia and the reference area (3)• inherent risks, such as antihypertensivc drug ther- apy (?), the idea of focusing only on the top few percent at reallr high risk implies that we drill leave the 15-209b who are hy'pertenstve and the even larger number who are hypcrcholestcrolaernic to die preNnaturelp from eroronary disease, without ippi)arg tl,~x ple.eent.•t u,ceauta.a :1lat erL t.hl: free. Modcratimn of dietart• sodium, saturated fats, and ealaraes does not impose, in Oliver's a~ords, "a Cal- vinistic life-style for us all" but rather tries to break some of the unnatural and unhealthy dietary habits we have so tecenth• adopted. 0 1. Jmma/ of rGt Ammtan Afrdrral Arraa'antin, 248: 1465 (1982). 2 I+APL.,,h.N. 1(. Joxmal o,Jrbr Ar.enimn 11'Ard'wrl Aaam• tion, 249; 365 (1983). talitl• in North Karelia had continued. For 1969-'9, which includes eight years of ihtervcn- tion. Oliver gives the reductions in age-standard- ized mOe coronan• heart disease mortahty~ ss 24% in North Karelia, 21 % in the reference area, and 12% in Finland outside North Karclia. But he should have citedourpaperfunher: since the inter- vention programme started onlv after the spring of 1972, it is important to note that most of the reduc- tion in North Karelia took place after 1973, while the reference area had a substantial reduction aI- readc bt:fore the programme started. The table shows that the reduction in age-srandardu:ed cor- onan hkan disease mortality in men in 1974-79, based on smoothing the curve by linear regression, was about twofold in North Karelia compared with the refekence area or the rest of Finland (P<0.05, compared with North Karelia). The reductions in age-standardized male coronary heart disense mor- After 10 years of ihe programme, risk•factor lev- Decline in aee-atanderdited coeonary heart dlaesae els fell further (4), and when we analyscd the latest mortality based on average annual t•egrossion. North coronary heart disease mortality trends for the per- Keretla, the reference area. and Finland lests North 479 iod 1969-79 (5) for 11onh l:arelia, the refcrence Karelia.197 (= 95% confidence intervala) roj er count s i nce h e p ect t county, an ll ot h i es - d a might also have spccial inAuence on the reference area-the derllne in coronare heart disease mor• The Wtrters are w4h,lhe Department of EpitlemiotogY, National Public Health 'nstltute. Helsinki. Flnland, the Research Instqute of public Health. University of Kuopio. and the OH,ce tor Heanh Educauon. National Board of Heanh• Helsinki Annuat % declene in 1974-79 Are9 Men Women North Karelia 3 7_ 1 5 2.2 x 3 4 Reterence al'e t.9 s 2.3 1 6 s 1 4 Pmlenlf leas Norrh Kereha 1-7 z Z 20 1 2 s? 4 s O,new,,re e.on+ honn sneue .n rounon ro ,aroom rane+on P<0 05 sooae s.v'rro• .r o, a. amun m.arerre,rma~ 236 9asf /1as31 • t.,t t I...a I _nRIJ1 Iti.4L-tlt/iBlNf \;•L 1 1^ea

ROUND TABLE talit,v from 1974 to 1979 w~ere 2296 in North Kar- elia, 12 % in the reference area, and 1196 in the whole couittn•. We think that th+, i- r.-c-e t!:_r °e lirtle d i fference" -both in percentage and in abso- lute number of reduced premature eoronan• heart disease deaths in the area These results do not prove a causal association but they dosuggest that a comprehensive risk•factor reduction programme can lead to reduced disease rates in the communin•. Public health decisions on risk-factor reduction must be based on broad information about the overall expected favourable and harmful conse- quences of such actis•ity. Community studies in.•es- ttgate several questions relevant to prevention and community health in a real-life situation. Thus the North Karelia project has, besides assessing risk factor and disease changes, yielded information about the feasibility of the programme and turned up other positive findings such as reduced disabihtr payments for cardiovascular disease, few•er re- ported general health complaints and emotional problems, and popular satisfaction with the activity (6). A community study can also give valuable infor- mation about the relation between risk factors and coronary hesn disease. Randornired trials based on individuals have their limitations, especially since the life-styles in question are so much a community issue. A community-based intervention is likely to be a cheaper and perhaps more effective and natu• ral way to influence the life-stt•larelated risk fac- tors, as the results of the North Karelia project indicate. Oliver's conclusion is that general risk-factor reduction programmes are not justified and may do Intervention limited to people at high risk canttot have much of a long-tetm commurity impact. harm. Even if we disregard the above results, w•e feel that w•c have good reason to promote general nsk•factor reductions in whole populations. Stop- ptng smoking has mam• health benehts; reduction of ohcstw and increased vegetable and fibre con- sumption are likely to be bcnetictal: and treatment ot estahhshrd h.%pcttension ts w•arranted. People should be helped to make changes that a great pro- Portion of them want and that reduce the nsk of Jiacaaca and premature death and promote hcalth. These factors are common in the eommunitv and are closely linked with general life- Stcles, sn inv tnrrn•rnrrr,r 1•rr.:rc'! :: Yecr!::1 rtsk cannot have much of a long-term community impact. lit communtn•-based interventions people themselves ultimately make the decisions about their health practices and Fife-sty9es. The changes recommended by a recent WHO expert group (7) on the prevention of coronarp heart disease, are ntoderate and safe, can be enlovable, and are likely to reduce the risk of several malor noncommunic- able diseases and promote health in general. Peo~~ ple kave a right to this information and to be helped to make such changes. 0 1. Pl;stC1 P. rT AL B.itub nrtdrrol jonnml. 2: 1173 (19:9). 2. S.1LvNE\. J. T. Er AL rlnrmranjaitm,rl ofrpidrrmarogr, 114:81 (1981). 3: SALOSEx. J. T. t:T AL Bnrub ardtrdjourno/ 2: 1176 (19?9). 4. Pt'st:.i. P. ET AL 6arirb mrdrml jo,.nal, 2: 1840 (1983) . 5. SALOXE.%. ). T. Ei AL Bnrrrb mrdord jonMal, 286: 117 (1983). 6. PL'St:A, P. ET AL Tbr ]Vo»b Korr6e projrer. Copenhagen, %C'orld Health Organization, 1981. 7. Pmrnrroa oJ roroeagr hrarr d(nerr. Geneva, World HealthOrganrratron, 1982 (Technical ReponSenes, No. G78). Mlichael Oliver - Data not contrincing The excellent balanced l.mral editorial on diet and coronary heart disease nghtly emphasizes the de- gree of consensus between proponents of the masa population approach and proponents of the strategy of focusing on those at high risk. It states that both the %Y'HO facpen Committee and I "agree that attempts at dietary modification are, in principle, likelr to be successful in their different targd groups". This answers Professor 1lorns, who tncorrectl±• tnaerprets my recent paper as recommending that w•e should do nothing on diet: I have consistently taken the view that some dietary modification is dcsrrab:c (1). Whtle \\'IlO recommendations, as applied in the mulnple risk factor intervention trial, faded almost certainly because the+• were too IG wi.aLD iII '. , v 11 aI