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From Framingham to North Karelia to U.S. Community-Based Prevention Programs: Negotiating Research Agenda for Coronary Heart Disease in the Second Half of the 20th Century
Public Health Reviewsvolume 33, pages450–483 (2011)
In the United States in 1948, the newly formed National Heart Institute (NHI) responded to what its data showed as a rising tide of coronary heart disease (CHD) by underwriting new approaches to the elucidation of chronic disorders. In the process, it funded the application of epidemiology, previously almost exclusively concerned with communicable disease, to study CHD. With federal encouragement, CHD epidemiologists enriched research designs, helped develop the randomized controlled trial, and played a pioneering role in chronic disease prevention at the individual and population levels. While government funding was critical to the evolution of this rich scientific work, a vibrant epidemiological imagination was able to capitalize on decades of national political commitment to chronic disease research. Epidemiologists developed longitudinal studies meant to determine the relationship between well-measured clinical variables and subsequent CHD events. Here, consistent associations within and across populations, eventually reinforced by analyses of pooled data from multiple cohort investigations, demonstrated the existence of well-founded risk factors, but left open the question of causal inference based on observed relationships. After substantial ambivalence, the U.S. government, under pressure from epidemiologists, committed to an agenda of clinical trials to test that proposition. In addition, the results of the cohort studies elicited a demand by epidemiologists for a broader, population-wide approach, testing whether community-level models of risk factor modification through broad cultural change would demonstrate a reduction in the probability of disability and premature death from heart attack.
To tell the story of the community studies and to analyze outcomes, we focus on the Minnesota Heart Health Program and the Finnish North Karelia Project. From the North Karelia experience, we find that health promotion campaigns in communities at very high risk of disease, where the population lives in traditional patterns and considerable poverty and is also unsophisticated in health knowledge and behaviors, are more likely to achieve major and measurable population effects. We argue that as chronic disease rates rise globally, and CHD rates increase in lower- and middle-income nations, as they have over the past several decades, population-level prevention interventions have become particularly relevant. But it remains to be seen whether the international community, prodded by its member states, can successfully reproduce the urgency and agenda-setting that sparked the successful epidemiologic and public health interventions in the affluent countries in the decades after World War II.
Strickland SP. Politics, Science, and Dread Disease. Cambridge, MA: Harvard University Press; 1972.
Dublin LI. Health Progress, 1936 to 1945. New York, NY: Metropolitan Life Insurance Co. N.D.
Fox DM. Power and Illness: The Failure and Future of American Health Policy. Berkeley, CA: University of California Press; 1993.
Etheridge EW. Sentinel for Health: A History of the Centers for Disease Control. Berkeley, CA: University of California Press; 1992.
Mountin JW. Changing concepts of basic local public health services. In: Selected Papers of Joseph W. Mountin, M.D. Joseph W. Mountin Memorial Committee; 1956.
Dawber TR. The Framingham Study: The Epidemiology of Atherosclerotic Disease. Cambridge, MA: Harvard University Press; 1980.
Oppenheimer GM. Becoming the Framingham Study 1947–1950. Am J Public Health. 2005;95:602–10.
Marks HM. The Progress of Experiment: Science and Therapeutic Reform in the United States, 1900–1990. Cambridge: Cambridge University Press; 1997.
Keys A. Nutrition in relation to the etiology and the course of degenerative diseases. J Am Diet Assoc. 1948;24:281–5.
Katz LN, Stamler J, Pick R. Nutrition and Atherosclerosis. Philadelphia, PA: Lea & Febiger; 1958.
Aronowitz RA. The social construction of coronary heart disease risk factors. In: Aronowitz RA, editor. Making Sense of Illness: Science, Society and Disease. New York, NY: Cambridge University Press; 1998. p.111–44.
White PD. Heart Disease. 3rd edition. New York, NY: The Macmillan Co; 1944.
Moriyama IM, Woolsey TD, Stamler J. Observations on possible factors responsible for the sex and race trends in cardiovascular-renal mortality in the United States. J Chronic Dis. 1958;7:401–12.
National Heart Institute. Circular number 7. October 1951. Cited in Katz LN, Stamler J. Experimental Atherosclerosis. Springfeld, IL: Charles C. Thomas; 1953.
Meadors G. Minutes. In: Records of the National Institutes of Health, National Advisory Heart Council, Box 21, National Archives, College Park, Md. June 7, 1948.
Clausen JA. Research on the American soldier as a career contingency. Soc Psychol Q. 1984;47:207–13.
Moore F. Correspondence to Van Slyke CJ. August 26, 1949. In: Papers of the National Heart, Lung, and Blood Institute, Framingham Heart Disease Epidemiology Study (General) Folder.
Meadors G. Correspondence to Boone B, July 19, 1947. In: Papers of the National Heart, Lung, and Blood Institute, Epidemiology Correspondence Folder.
Dawber TR, Moore FE, Mann GV. Coronary heart disease in the Framingham Study. Am J Public Health. 1957;47:4–24.
Doyle JT, Dawber TR, Kannel WB, Heslin AS, Kahn H. Cigarette smoking and coronary heart disease: combined experience of the Framingham and Albany studies. N Engl J Med. 1962;266:796–801.
Cornfeld J. Joint dependence of risk of coronary heart disease in serum cholesterol and systolic blood pressure: a discriminant function analysis. Fed Proc. 1962;21:58–61.
Rothstein W. Public Health and the Risk Factor: A History of an Uneven Medical Revolution. Rochester, NY: University of Rochester Press; 2003.
Aronowitz R. The social construction of coronary heart disease risk factors. In: Aronowitz R. Making Sense of Illness: Science, Society and Disease. New York, NY: Cambridge University Press; 1998. p.111–44.
Dawber TR, Kannel WB. Application of epidemiology of coronary heart disease to medical practice. Modern Medicine. 1962;30:85–101.
Max H, DeMets DL, Ware JH. Early Methodological Developments for Clinical Trials at the National Heart, Lung and Blood Institute. Stat Med. 1990;9:881–92.
Turpeinen O, Miettinen M, Karvonen MJ, Roine P, Pekkarinen M, Lehtosuo EJ, Alivirta P. Dietary prevention of coronary heart disease: long-term experiment. I. Observations on male subjects. Am J Clin Nutr. 1968;21:255–76.
Dayton S, Pearce ML, Hashimoto S, Fakler LJ, Hiscock E, Dixon WJ. A controlled clinical trial of a diet high in unsaturated fat. N Engl J Med. 1962;266:1017–23.
National Diet-Study Recruitment Group. The National Diet-Heart Study final report. Circulation. 1968;37:S119–24.
National Heart Institute. Diet-Heart Review Panel. Mass Field Trials of the Diet Heart Question. New York, NY: American Heart Association; 1969.
National Heart Institute. Diet-Heart Review Panel, National Heart and Lung Institute Task Force. Arteriosclerosis, A Report by the National Heart and Lung Institute Task Force on Arteriosclerosis. Washington, DC: U.S. Printing Office; 1971.
Coronary Drug Project Research Group. Clofibrate and niacin in coronary heart disease. JAMA. 1975;231:360–81.
National Advisory Health Council. Transcripts of Proceedings, 62. 1975.
Freis E.D. Reminiscences of the Veterans Administration trial of the treatment of hypertension. Hypertension. 1990;16:472–5.
World Health Organization European Collaborative Group. European collaborative trial of multifactorial prevention of coronary heart disease: final report on the 6-year results. Lancet. 1986;1(8486):869–72.
Hjermann I, Holme I, Leren P. Oslo Study Diet and AntiSmoking Trial. Results after 102 months. Am J Med. 1986;80:7–11.
Cooper T. Arteriosclerosis: policy, polity, and parity. Circulation. 1972;45:433–40.
Multiple Risk Factor Intervention Trial Research Group. Multiple Risk Factor Intervention Trial. Risk factor changes and mortality results. JAMA. 1982;248:1465–77.
Hypertension Detection and Follow-up Program Cooperative Group. The effect of treatment on mortality in “mild” hypertension. Results of the Hypertension Detection and Follow-up Program. N Engl J Med. 1982;307:976–80.
Lipid Research Clinics. The Lipid Research Clinics Coronary Primary Prevention Trial results 1. Reduction in incidence of coronary heart disease. JAMA. 1984;251:351–64.
The Pooling Project Research Group. Relationship of blood pressure, serum cholesterol, smoking habits, relative weight and ECG abnormalities to the incidence of major coronary events: final report of the Pooling Project. J Chronic Dis. 1978;31:201–306.
Farquhar JW, Maccoby N, Wood PD, et al. (1977). Community education for cardiovascular health. Lancet, 1977;1:1192–5.
Keys A, et al. Coronary heart disease in seven countries. Circulation. 1970; 41:S1–211.
Blackburn H. Research and demonstrations projects in community cardiovascular disease prevention. J Public Health Policy. 1983;4:398–421.
Report of the Makarska Conference on Mass Field Trials for the Prevention of Coronary Heart Disease. International Society of Cardiology. Makarska, Yugoslavia. CVD History Archive: School of Public Health, Univ. of Minnesota; 1968. Available from URL:http://www.epi.umn.edu/cvdepi/ photo_doc.asp?id=981 (Accessed 22 December, 2011).
Puska P, et al. The North Karelia project. 20-year results and experiences. Helsinki: National Public Health Institute; 1995.
Mass Field Trials on the Prevention of Coronary Heart Disease: Perspectives and Tasks. Report of an International Working Meeting Makarska, Yugoslavia, 19–24 September, 1968. Available from URL: http://www.epi.umn.edu/cvdepi/ pdfs/Makarska%20doc.pdf (Accessed 22 December, 2011).
Farquhar JW, Fortmann SP, Maccoby N, Haskell WL, Williams PT, Flora, JA, et al. The Stanford Five-City Project: Design and methods. Am J Epidemiol. 1985;122:323–34.
Jacobs DR Jr, Luepker RV, Mittelmark MB, Folsom AR, Pirie PL, Mascili SR, et al. Communitywide prevention strategies: Evaluation design of the Minnesota Heart Health Program. J Chronic Dis. 1986;39:775–88.
Carleton RA, Lasater TM, Assaf A, Lefebvre RC, McKinlay SM. The Pawtucket Heart Health Program: an experiment in population-based disease prevention. R I Med J. 1987;70:533–8.
Murray DM. Design and analysis of community trials: Lessons from the Minnesota Heart Health Program. Am J Epidemiol. 1995;142:569–75.
Blackburn H. Community programmes in coronary heart disease prevention and health promotion: Changing community behavior. In: Coronary Heart Disease Epidemiology. Marmot M, Elliott P, editors. New York, NY: Oxford University Press; 1992.
Winkleby MA, Feldman HA, Murray DM. Joint analysis of three U.S. community intervention trials for reduction of cardiovascular disease risk. J Clin Epidemiol. 1997;50:6545–658.
Kannisto V. Kuolemansyyt väestöllisinä tekijöinä Suomessa. [Finnish]: Causes of death as demographic factors in Finland. Helsinki: Kansantaloudellinen yhdistys; 1947.
Keys A. The cholesterol problem. Voeding. 1952;13:539–55.
Keys A, Karvonen MJ, Fidanza F. Serum-cholesterol studies in Finland. Lancet. 1958;2:175–8.
Roine P., Pekkarinen M., Karvonen M.J., Kihlberg J. (1958). Diet and cardiovascular disease in Finland. Lancet. 1958;2;173–5.
Editorial. Shot-gun prevention? Int J Epidemiol. 1973;2:219–20.
Puska P, Tuomilehto, Nissinen A, Vartiainen E. The North Karelia Project 20 year results and experiences. Helsinki: National Public Health Institute; 1995.
Puska P, Vartiainen E, Laatikainen T, Jousilahti P, Paavola M, editors. The North Karelia Project: From North Karelia to National Action. Helsinki: The National Institute for Health and Welfare (THL); 2009.
Vartiainen E, Laatikainen T, Peltonen M, Juolevi A, Männistö S, Sundvall J, et al. Thirty-five-year trends in cardiovascular risk factors in Finland. Int J Epidemiol. 2010;39:504–18.
Laatikainen T, Critchley J, Vartiainen E, Salomaa V, Ketonen M, Capewell S. Explaining the decline in coronary heart disease mortality in Finland between 1982 and 1997. Am J Epidemiol. 2005;162:764–73.
Puska P, Nissinen A, Tuomilehto J, Salonen JT, Koskela K, McAlister A, et al. The community-based strategy to prevent coronary heart diseases: conclusions from the ten years of the North Karelia Project. Ann Rev Public Health. 1985;6:47–193.
Puska P, Ståhl T. Health in All Policies–The Finnish Initiative: background, principles, and current issues. Ann Rev Public Health. 2010;31:27.1–27.14.
Community Intervention Trial for Smoking Cessation (COMMIT): I. cohort results from a four-year community intervention. Am J Public Health. 1995;85:183–92.
Luepker RV. Community trials. Preventive Med. 1994;23:602–5.
Luepker RV, Murray DM, Jacobs DR, Mittlemark MB, Bracht N, Carlaw R, et al. Community education for cardiovascular disease prevention: risk factor changes in the Minnesota Heart Health Program. Am J Public Health. 1994;94:1383–93.
Susser M. The tribulations of trials-interventions in communities. (Editorial) Am J Public Health, 1995;85:156–8.
About this article
- History of CVD epidemiology
- coronary heart disease
- chronic disease
- non-communicable disease
- Minnesota Heart Health Program
- North Karelia Project
- community studies
- randomized controlled trial
- primary prevention
- community-based primary prevention programs