It's a cool April morning at Seinäjoen Yhteiskoulu and patches of snow can still be found in the schoolyard. In one of the classes, teacher Laura Jokiranta whistles loudly with her fingers -- the sign for her students to start running.
There are, no doubt, many biology teachers around the world who would view the use of fitness games in the classroom with some skepticism. But Jokiranta includes them almost daily, as do the other teachers at the school in Seinäjoki, a town of 60,000 in western Finland. It is part of a preventative program that has caught the attention of health experts across the globe. Within the space of just a few years, the city has been able to significantly reduce the number of overweight and obese children.
Just seven years ago, 17 percent of all five-year-olds fell into that category. By 2015, it was down to 10 percent. The change for older children wasn't as significant, but that is hardly surprising given the relatively short time the program has been in place, says Ulla Frantti-Malinen, who coordinates it.
Still, health authorities in many countries can only dream of such results. Growing numbers of children are getting increasingly fat, particularly in countries like Mexico and the United States, where over 30 percent of children are overweight.
Not only does obesity make childhood more difficult, the problems also continue into young adulthood and beyond, with an increased risk of suffering from problems like diabetes, lipometabolic disorder and cardiovascular disease.
OVERWEIGHT CHILDREN -- A GLOBAL PROBLEM
The World Health Organization (WHO) estimates that 41 million children under the age of five are already overweight or obese globally -- or over 6 percent. As recently as 1990, that number was just 32 million.
According to the results of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS), 15 percent of children in Germany between the ages of three and 17 are overweight, with one-third of those children already suffering from obesity. The consequences are significant for the German healthcare system.
Due to a combination of poor nutrition, such as overconsumption of sugary soft drinks and fast food, and insufficient exercise, diseases such as diabetes have become much more common among younger age groups.
Finland was not immune to the problem. But with weights on the rise and the number of adults suffering from type 2 diabetes -- which is often triggered by obesity -- increasing, the state health agency in Helsinki sounded the alarm and informed municipalities about the problem to raise awareness.
The issue was particularly prevalent in the region of Etelä-Pohjanmaa, where Seinäjoki is located. In response, representatives of local institutions in the city met in 2013 and developed their own program. Nobody at the time expected it to be as successful as it has been, but even WHO has since written about Seinäjoki.
As a consequence, the town has received an increasing number of delegations from abroad, with even the South Korean capital of Seoul set to adopt the Seinäjoki program, not to mention several other municipalities across Finland.
But what are the Finns doing right? The answer is multifaceted and likely has something to do with the Finnish mentality, which tends to take an uncomplicated, pragmatic approach to problems.
It is an approach that begins in the womb.
THE FINNISH SYSTEM
As early as 8 a.m., the first pregnant women are sitting in the hallway of a low, red-brick building for the beginning of consultation hours. They are there for neuvola. Health-care consultant Liisa Mikkola enters one of the plain rooms in the buildings and explains what her job is. "Ninety-nine percent of all Finns come to us, almost everybody takes advantage of neuvola," the former nurse says.
A direct translation of the term is difficult: neuvo is the word for "advice" and the suffix la refers to a "place." For decades, the centers in Finland have focused on providing support to young parents and their children -- from family planning and pregnancy to infant care and assistance all the way up to kindergarten age.
Other countries, of course, also have specific programs to help new families: In Germany, for example, parents are obliged to take their children in for nine medical checkups between birth and five years of age. But neuvola offers more.
The program includes home visitations, for example, and women come for advice far more often.
When the health authorities of Seinäjoki gathered together all the participating experts in 2013, Mikkola was also present. Since then, she has been devoting much more energy than ever before to the fight against excess weight and for better childhood nutrition. But implementing changes isn't so easy, she says. After all, it isn't the children who are to be blamed for their weight problems, it is their parents.
Together with her team, Mikkola also organizes the support provided to schools in Seinäjoki. Every facility has its own school nurse and some even have a doctor. "Our goal is to transform healthy children into healthy adults," she says.
The finely woven net of consultation, early diagnosis and prevention helps ensure both the success and the sustainability of the neuvola system. Because of frequent contact and widespread acceptance, health workers can react quickly to changes they observe in children.
THE SUGAR-FREE KINDERGARTEN
Just how difficult it is to change bad habits is a lesson learned by, among others, the otherwise tremendously successful British TV chef Jamie Oliver.
A few years ago, he set out to make school meals in Great Britain healthier and to rid cafeterias of soft drinks, pizza, Turkey Twizzlers and other unhealthy items.
The program, known as Feed Me Better and provided with millions in government funding, achieved some long-term benefits, but it wasn't universally accepted. Many students refused to eat Oliver's healthy new meals and some parents even brought their children fast food during the lunch break.
The vending machines full of Xylitol lozenges, which stand in the cafeteria of Sivusalmi's kindergarten, would likely turn heads almost anywhere else in the world. Xylitol is a sugar-free sweetener that can be made out of tree bark (in Finland, it tends to be made from birch). In the kindergarten, it doesn't just serve as desert after lunch, it also helps protect against dental cavities.
The substance is often used in sugar-free chewing gum as a way of improving dental hygiene. In Seinäjoki, dentists too are part of the program.
RED MEANS BETTER LEARNING
At Seinäjoen Yhteiskoulu, the lunch break has just come to an end and the children stream out of the cafeteria heading for their classrooms. School director Jari Naponen ate with them, and now he stands up and points to a colorful poster hanging on the stairwell wall. It is from a study conducted by the American doctor Charles H. Hillman and shows the brain activity of two people shortly before a school test.
The subject on the left simply sat for 20 minutes before the test and the active regions of the brain are shaded in subdued colors ranging from green to yellow. The other subject spent 20 minutes on a treadmill before the test and the deep red on the image shows much greater brain activity. The red color is the source of Naponen's motivation. "I love this picture," he says.
Naponen was a physical education teacher before he became the school's director 15 years ago. He was always of the opinion that P.E. classes alone were insufficient to ensure that schoolchildren engaged in enough physical activity. "Our children don't get enough exercise. They sit too much and very few of them walk or ride a bike to school. The distances here in Finland are sometimes too great for that. Some of my students come to school on a tractor," he says.
Naponen's school also has a mandatory break during which children must go outside to get some fresh air, even in the depths of the Finnish winter.
In a seventh-grade geography class, Matti stands up in the middle of the lesson and does a couple of chin-ups on a bar on the wall. Most teachers would be appalled, but Matti's teacher simply looks on in approval. Everyone at the school has learned to value the fitness of their students and students are allowed to get up at any time for a bit of exercise. In contrast to expectations, many teachers say that their students on the whole are actually calmer than they were before.
Few doubt Naponen's vision anymore, particularly since the school has won several prizes as a result. In 2013, Seinäjoen Yhteiskoulu was even chosen as Finland's school of the year. But success did not come overnight. "At the beginning, I felt like Don Quixote, fighting against windmills," he says. But now, teachers like Laura Jokiranta have fun coming up with new exercise ideas for all kinds of classes. "When one person gets excited, it infects the others," Noponen says.
The many small elements of the Seinäjoki Project have been successful despite a lack of outside funding: No money was made available by the Finnish government. All of those involved emphasize that success has been a product of the way the various institutions involved complement each other, from the school to neuvola. There is no fighting over resources and nobody gets in each other's way. Critics have noted that it is impossible to isolate the effects of each individual element. But if you ask Noponen what the secret is, his answer is strictly pragmatic: "No idea. I don't know. I only know that it works," he says. "And that's what counts."
THE MIRACLE OF NORTH KARELIA
It is not the first time that a Finnish prevention program has found great success. Pekka Puska, 70, is something like the éminence grise of prevention in Finland and his work has had a significant influence on public health in the country.
Formerly the director of Communicable Disease Prevention and Health Promotion at WHO, Puska first gained recognition as a 27-year-old, when he was put in charge of a project that received widespread attention. In the 1970s, the province of North Karelia, located on the border with Russia, had a heart-attack rate among middle-aged men that was higher than anywhere else in the world. The men, though, were not notably overweight. Indeed, most of them had physically demanding jobs as farmers or loggers.
But Puska and his team were able to identify the roots of the problem and by 2006 the heart attack rate in the province had plunged by an astounding 85 percent. The team discovered that the men of North Karelia consumed vast quantities of butter and meat in addition to being heavy smokers. "People slowly began realizing at the time the role that such factors play," Puska says. He was uninterested in finding better treatments for heart attack patients. He sought to prevent them from having them in the first place.
How, though, can you change the lifestyle of an entire generation?
Instead of just giving lectures to experts about the problem, telling them that cigarettes and butter should be avoided, Puska and his team went straight to the people themselves. "We did a lot of work in the communities," he says. He held training sessions for members of the Martta Organization, a large association of women, teaching them to use vegetable oil instead of butter and to cook more greens and less meat. Puska is a charismatic man and he was able to convince the women of the benefits of the new approach. There is even a dish named after him in Finland, "Puska's Stew," which contains plenty of vegetables.
He also developed relationships within the food industry and worked hard to nurture them. A sausage manufacturer, for example, took Puska's message to heart and began using less salt. Puska was also able to have an effect on cigarette smoking, with a nationwide ban on tobacco advertising being introduced in 1978. Furthermore, competitions were organized in the municipalities, awarding prizes to those who could sink their cholesterol levels the most.
In hindsight, he believes his success depended primarily on word of mouth. "You have to try to convince opinion leaders. If you can do that, your message will spread by itself," he says. The same thing happened in Seinäjoki. Everybody there is familiar with Puska's success story and his ideas have been implemented in the city's program. The same thing could happen elsewhere.
HOW GERMANY FIGHTS EXCESS WEIGHT
Germany, too, has a problem with children and adolescents sitting for too long in front of the computer, drinking too many soft drinks and eating too much fast food. Prevention programs have had a hard time gaining long-term traction in the country, even if they have had some success. Health insurance companies have long relied on the distribution of informational flyers and have expended little effort on prevention.
"Simply distributing info-material does little," says pediatrician Helge Hebestreit, who developed a prevention program for 20 kindergartens which envisions 30 minutes of exercise per day. It was tested in Würzburg in Bavaria and its surroundings for a year in 2007. The goal was to influence the children before they started school and to teach them that exercise can be fun.
It worked. "Motor skills measurably improved as a result of the program and physical activity increased," Hebestreit says. The parents got involved as well, with the children being given exercise homework, such as brushing their teeth while standing on one leg. Hebestreit hopes to carry out an additional study to measure the program's long-term effects, but it is unclear whether it will go forward. He needs to find more kindergartens to take part. "The lack of comprehensive implementation is a problem," he says.
Exercise Starts in Kindergarten
Even just developing the study has been incredibly laborious, he adds. "The concept has to be implementable for each of the many different kindergartens," he says. It is a bit easier in schools, since they are administered by the state. But here too, Hebestreit has had bad experiences. When he tried to launch a follow-up program in the schools, he says the project became bogged down in the state Education Ministry.
Prevention experts can almost certainly forget about the nationwide implementation of a program, no matter how successful it might be. German federalism, which holds that states are responsible for education, is simply too complicated. Puska is convinced that it is easier in Finland, with its centralized system of comprehensive schools, which all children attend until the ninth grade. Everyone here goes to the same kind of school," he points out.
Finland is much further along than Germany, says Hebestreit. Preventative medicine has been practiced there for a long time and enjoys significant political support. In Germany, by contrast, health insurance companies never really felt responsible and sought at most to fulfill their preventative mission with expensive and useless flyer campaigns. "For a long time, health insurance companies were only concerned with the sick," he says. "Thankfully, that has now changed." Germany's new law on preventative medicine, passed last summer, very clearly places prevention under the remit of health insurance companies.
Hebestreit is not surprised by the results achieved by the Finnish town. "Without doubt, a community can do a lot when it implements several measures at the same time," he says. "And when everybody pulls together."
That's what happened in Seinäjoki. Recently, a joke has been making the rounds among employees at the local health office. "Someone must have put something in the water that makes the children thin," project coordinator Ulla Frantti-Malinen says with a smile. What triggered their success isn't so important. The main thing is that they've found it.
This report is part of Expedition #BeyondTomorrow.
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