1. Nutrition in Health and Disease: Implications for Public Health in Russian Federation First Forum on NCD (Non-communicable Disease) Prevention and Healthy Lifestyle Promotion October 10-11, 2012 Keith C. Norris, MD, FACP Professor and Executive VP for Research and Health Affairs, Charles R. Drew University Assistant Dean for Clinical and Translational Science, Geffen School of Medicine, UCLA

2. Healthy citizens are the greatest asset any country can have - Winston Churchill Trinity Lavra of St. Sergius or Troitse-Sergiyeva Lavra – a World Heritage site

3. Overview/Objective of Presentation Russian Federation State of Health Review the role of noncommunicable diseases (NCD) on health in Europe and the Russian Federation Public Health Recommendations for Nutrition as a key NCD risk factor

4. Factors Associated with Global Mortality Factors Percentage 1. High blood pressure (BP)* 12.8 2. Tobacco use8.7 3. High blood glucose* 5.8 4. Physical inactivity 5.5 5. Overweight and obesity* 4.8 6. High cholesterol* 4.5 7. Unsafe sex 4.0 8. Alcohol use*3.8 9. Childhood underweight* 3.8 10. Indoor smoke from solid fuels 3.3 59 million total global deaths in 2004 - World Health Organization *Nutrition related risk factors

5. Global Mortality Risks High BP is the leading mortality risk factor followed by tobacco – Together responsible for over 20% of deaths globally Low fruit and vegetable intake, lack of exercise, alcohol and tobacco use, high BMI, high cholesterol, high blood glucose, and high BP: – responsible for more than half of CV deaths, the leading cause of death in the world. Overweight/obesity is the 5 th leading risk for death. – Responsible for 7 per cent of deaths globally. World Health Organization

6. Impact of Selected Diet-related Risk Factors on Disability World Health Organization -2004 DALYs: Attributable Disability-Adjusted Life Year Rates for Selected Diet-related Risk Factors

7. Probability of Being Healthy by Age, Sex and Region Andreev EM, McKee M, Shkolnikov VM. Health expectancy in the Russian Federation: a new perspective on the health divide in Europe. Bull World Health Organ. 2003;81(11):778-87.

8. Life Expectancy Between 1980 – 1998 For The Russian Federation, Other NIS, Select Eastern European Countries, Japan and the United States Food security in the Russian Federation at www.fao.org/docrep/007/y5069e/y5069e06.htm Survival rates are low but increasing in Russia !

9. Develop and strengthen policies/programs on healthy lifestyles and NCD prevention. – Global strategy for the prevention and control of NCDs and its action plan – National health plans and sustainable development frameworks. Highlight the magnitude of the impact of NCDs Review experience on NCD prevention/control; Provide evidence to strengthen global and national initiatives to prevent/control NCDs Moscow 2011 Conference on NCDs: Russian Federation and WHO

10. Red Square and Moscow Kremlin – a World Heritage site Decree to improve population health outcomes on May 7 th, 2012* - President Vladimir Putin *Prevention of Non-Communicable Diseases

11. 2008-2013 WHO (World Health Organization) Action Plan for the Global Strategy for the Prevention and Control of Non-communicable Diseases

12. Major Nutritional Problems in the World Protein-energy malnutrition Obesity Micronutrient deficiency – Iron deficiency anemia – Vitamin A deficiency – Iodine deficiency disorders – Zinc deficiency – Folate deficiency – Others? Nutrition-related chronic diseases – Need for high quality foods – Medical nutrition

13. Morbidity and mortality risk factor – Increased risk of premature death – Diabetes, heart disease, hypertension, some cancers, others Russia: Prevalence of obesity – ~20%* Russia: Prevalence of overweight/obese – ~50% U.S. : Prevalence of obesity - ~34%* U.S. : Prevalence of overweight/obese – ~65% Public Health Importance of Nutrition * Sources: OECD Health Data 2011; national sources for non-OECD countries. Nutrition and Food security in the Russian Federation at www.fao.org/docrep/007/y5069e/y5069e06.htm CDC: http://www.cdc.gov/nchs/data/hestat/obesity_adult_07_08/obesity_adult_07_08.htm

14. Global Prevalence of Obesity WHO 2008 males

15. Lets Avoid the Obesity Trends Among U.S. Adults, (BRFSS 1990 – 2008) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% 30% CDC Behavioral Risk Factor Surveillance System (BRFSS); 1990 Obesity = (*BMI 30, or ~ 30 lbs. overweight for 5 4 person 2008 Obesity rates in the US have doubled in less than 30 years!!!

16. Increase in fat cells leads to increase release of adipokines Hormones and signaling factors that increase: Inflammation Oxidative stress Blood pressure Diabetes Other There may be times when that is helpful for survival In a sedentary, western style civilization excess adipokines are harmful Why is Fat Bad? Fain JN, Tagele BM, Cheema P, Madan AK, Tichansky DS. Release of 12 adipokines by adipose tissue, nonfat cells, and fat cells from obese women. Obesity (Silver Spring). 2010 May;18(5):890-6.

17. 1. Raise NCD priority in development work at global and national levels 2. Establish and strengthen national policies and plans for the prevention and control of NCDs 3. Promote interventions to reduce the main shared modifiable risk factors for NCDs: – tobacco use, unhealthy diets, physical inactivity and harmful use of alcohol 4. Promote research for NCD prevention/control 5. Promote partnerships for NCD prevention/control 6. Monitor and evaluate progress of NCDs and their determinants. 2008-2013 WHO (World Health Organization) Action Plan for the Global Strategy for the Prevention and Control of Non-communicable Diseases

18. Promote and support exclusive breastfeeding for the first six months of life – Ensure optimal feeding for infants and young children Develop a national policy and action plan on food and nutrition OBJECTIVE 3: To promote interventions to reduce tobacco use, UNHEALTHY DIETS, physical inactivity and harmful use of alcohol 2008-2013 WHO Action Plan

19. Establish and implement food-based dietary guidelines and support healthy food composition by: – reducing salt levels – eliminating industrially produced trans-fatty acids – decreasing saturated fats – limiting free sugars OBJECTIVE 3 (continued): To promote interventions to reduce tobacco use, UNHEALTHY DIETS, physical inactivity and harmful use of alcohol 2008-2013 WHO Action Plan

20. Provide accurate and balanced information for consumers to promote well-informed, healthy choices Prepare and implement a framework and/or mechanisms for promoting the responsible marketing of foods and non-alcoholic beverages to children – reduce the impact of foods high in saturated fats, trans-fatty acids, free sugars, or salt. OBJECTIVE 3 (continued): To promote interventions to reduce tobacco use, UNHEALTHY DIETS, physical inactivity and harmful use of alcohol 2008-2013 WHO Action Plan

21. Healthy Russia: A Call To Action The Kazan Kremlin

22. Nutrition Related Public Health Strategies Key Actions Increased focus on a healthy diet and lifestyle Focus on prevention Motivate positive behavior change Increase awareness of risk of key medical conditions Key Outcomes Improve health and quality of life Reduce health care costs

23. Things to Watch for in Nutrition Messaging! Is attention drawn away from other modifiable risk factors? Are there decreased use of other services? Is there a false sense of security? Is there a too much focus on specific nutrients/foods? Are misleading claims being made? Are the public health messages being diluted or contradicted?

24. When you have exhausted all possibilities, Remember this...you haven't. - Author Unknown