CHAPTER 4 NUTRITION AND FOOD SECURITY

Availability and access are not enough to ensure food security in a country. People need to use food properly in order to provide nutritionally balanced diets, requiring knowledge on the nutritional needs of family members and on healthy diets. Contamination of food with micro-organisms, infectious diseases and inadequate feeding of children prevent proper utilization of food in the body. These factors partly set off the benefits of sufficient access to food and result in undernutrition. Lack of essential minerals and vitamins in the diet causes micronutrient deficiencies, related diseases and disabilities. Overconsumption of dietary energy leads to overweight and obesity. Unbalanced diets, overnutrition and non-nutrition-related factors are held responsible for a variety of chronic diseases, especially cardio-vascular diseases (CVD), which are major burdens in affluent countries.

In the present chapter anthropometric and dietary indicators of undernutrition, malnutrition and overnutrition are considered. Anthropometric data are utilized to identify the nutritional status and the main nutritional concerns of various groups of the population of the Russian Federation. The links between anthropometric indicators and poverty in the country are then considered. The connection between what has been called a “public health crisis” in the Russian Federation - the disturbing drop in life expectancy during the early 1990s - and diets is then investigated. Last, the diets of children and average diets are assessed.

The conclusions of this portion of the study are that in terms of the number of people affected, the main nutritional problems in the Russian Federation are overweight and obesity in adults and various micronutrient deficiencies in both adults and children, including iodine and iron deficiencies. Neither child nor adult undernutrition seems to be a sizeable problem in the Russian Federation. An investigation of nutritional outcomes by income indicates that overweight and obesity among both children and adults dominate findings in every income category. Even in the poorest group investigated, overweight and obesity are far more prevalent than underweight, indicating that undernutrition is a far lesser problem than overnutrition or malnutrition. This evidence points to the extraordinary significance among the Russian population of “subjective factors” such as dietary preferences and policy. Dietary preferences of the population were shaped by previous Soviet policies of subsidizing livestock product consumption and the erroneous belief that large amounts of calories and animal protein were needed to prevent undernutrition. The high prevalence of overweight and obesity and the health consequences - cardio-vascular disease, breast cancer, etc. - are largely a consequence of these erroneous beliefs and policies of the past.

Nutritional problems cannot be held responsible for the sharp decrease in life expectancy from 1992 and 1994. A considerable increase in alcohol consumption during that period seems to be the single most important cause of rising mortality rates in the early reform period. At the same time, once again, the long-term overall mortality pattern in the Russian Federation is strongly determined by nutritional factors, since it is dominated by cardio-vascular diseases (CVD), which are largely preventable by healthy eating, avoidance of smoking and heavy drinking, and adequate levels of physical activity.

Children’s diets in the Russian Federation are strongly influenced by the relatively low rate of infant breastfeeding. Nutritional deficiencies during pregnancy and infancy can raise the risk of chronic diseases in later life. Thus, reducing child malnutrition is in the long run a preventive measure against cardiovascular and other lifestyle-related diseases (Popkin, Richards and Montiero, 1996). Inadequate infant feeding practices, especially the low prevalence of breastfeeding, are hypothesized to cause decreased tolerance for infection and malnutrition in infants. For children 0-6 years, there is evidence of overnutrition, which could explain the high prevalence of overweight among five-year-olds. For older children there is some evidence of undernutrition.

Contrary to the perception of many Russians who experienced some degree of deprivation and insecurity during the reform period (Martinchik, Baturin and Helsing, 1997), no deficits in calorie and macro-nutrient consumption are found on the average during the transition process. The average diet of Russians has even become healthier since 1990 due to decreases in milk, meat and fat consumption and a rising share of starchy staples like bread and potatoes. A further change for the better is hampered by barriers to breastfeeding, poor knowledge of healthy diets, unfavourable food preferences (that emphasize animal products rich in fat and protein rather than fresh fruit and vegetables), false recommendations on dietary intakes as a legacy of the Soviet era and low levels of physical activity (WHO, 2000).

Nutritional status of different subpopulations in the Russian population

The main nutritional problems of the Russian population are stunting in children, micronutrient deficiencies for both adults and children and a high prevalence of overweight and obesity in adults. Most of these conclusions are derived from anthropometric indicators. Anthropometric indicators, derived from body parameters such as a person’s height and weight, are based on nutritional outcomes, rather than on adequacy of food intake. They are therefore perhaps a more reliable indicator of bottom-line, nutritional welfare. For children, anthropometric indicators compare height and weight for age to a reference group. Low height for age of a child compared to the reference population is called stunting and is presumed to reflect a sustained past episode or episodes of undernutrition. Low weight for age of a child compared to the reference population is called wasting, and usually results from weight loss associated with a recent period of starvation or disease. For adults, the individuals in the sample population are classified as underweight (Body Mass Index (BMI) < 18.5), normal (18.5 < BMI < 25), overweight (25 < BMI < 30) or obese (BMI > 30).^[20]

The following sections describe the nutritional status of various groups within the Russian population. Anthropometric indicators are described first, followed by indicators of micronutrient deficiencies. The indicators for the Russian Federation are then put in perspective by comparing them with similar indicators in other countries. The source of most anthropometric information is nationally representative data for children and adults collected in the Russia Longitudinal Monitoring Surveys (RLMS) in the period 1992 to 2000. The RLMS represents the first nationally representative random sample for the country (albeit a highly clustered one). The interview completion rate amounted to 84.3 percent. Further information on the sampling strategy, the survey schedule and the evaluation of samples is posted at http://www.cpc.unc.edu/projects/rlms/project.html.

Children

An important indicator of child malnutrition is the proportion of babies born with low birth weight (LBW). A high proportion of such babies can be indicative of nutritional deficiencies during pregnancy. The proportion of babies born with low birth weight (below 2 500 g) in the Russian Federation (7 percent) is not extraordinarily high by world standards. For comparison, the share of low birth weight babies in the countries of the European Union ranges from 4 to 7 percent (UNICEF, 1999). However, low birth weight statistics in the Russian Federation may exclude infants with a birth weight of less than 1 000 g because their chances of survival are so low (WHO 2000b). Thus, Russian LBW statistics may not be comparable to those of European Union countries.

FIGURE 11
Trends in children’s nutritional state (0-24 months)

Source: Zohoori, Gleiter and Popkin (2001).

FIGURE 12
Trends in children’s nutritional state (25-72 months)

Source: Zohoori, Gleiter and Popkin (2001).

Malnutrition for Russian children seems to begin after birth. Evidence from the RLMS suggests that the prevalence of stunting (low height for age) in the Russian Federation is extraordinarily high among infants (18.6 percent for children up to one year of age in 1995, according to author calculations with data from RLMS 2002) and that stunting is significantly correlated with overweight (Figure 11).^[21] Popkin, Richards and Montiero (1996) have found a similar association of stunting and overweight among Chinese, Brazilian, South African and elder Russian children. There are a number of hypotheses for the recent emergence of this pattern in countries undergoing the nutrition transition, yet no solid evidence on the actual causes to date. Given the concomitant prevalence of overweight in the Russian Federation, though, it is more likely that stunting is an outcome of a lack of micronutrients essential for growth and/or frequent infections followed by weight gain during infancy, rather than the consequence of deficiencies in the dietary energy intakes of young children. This reasoning points to problems in infant feeding practices.

For children aged 0 to 2 stunting (the indicator of chronic malnutrition) rose until 1994, then fell and finally rose slightly from 1998 to 2000 (Figure 11) (Zohoori, Gleiter and Popkin, 2001). A decline in income and food expenditure is probably responsible for this trend. In the fall of 2000 incomes were 10 percent lower than in the fall of 1995, and average real food expenditures had dropped to 69 percent of their 1995 level (Mroz, Henderson and Popkin, 2001). The trend for chronic malnutrition in the age group of two to six years is similar to that for younger children (Figure 12), though the upsurge in stunting is not observed before 2000. It is presumed that the rise of stunting in this age group is partly due to the stunted under-two-year-olds of 1998 reaching the upper age group by 2000 (Zohoori, Gleiter and Popkin, 2001). No marked differences were found in 2000 for indicators of child malnutrition disaggregated by sex: wasting was higher among girls under seven years of age by 0.3 percentage points, and the share of stunted females exceeded that of stunted males by 0.7 percentage points (author calculation with data from RLMS 2002).

FIGURE 13
Adult nutritional state (18-29 years)

Source: Zohoori, Gleiter and Popkin (2001).

FIGURE 14
Adult nutritional state (30-59 years)

Source: Zohoori, Gleiter and Popkin (2001).

Adults

The main nutritional problems in the Russian Federation for adults are overweight and obesity. Over 50 percent of adults are overweight or obese. These problems can lead to increased morbidity and mortality, particularly from cardio-vascular diseases and cancer. And, in fact, these are the preeminent health problems of the adult population in the country. The nutritional status of adults is shown in Figure 13, Figure 14 and Figure 15 by age group. The prevalence of underweight (Body Mass Index (BMI) < 18.5) has steadily increased from 1992 to 2000 in young adults aged 18 to 29 years. The incidence of overweight and obesity was 21.1 percent in young adults. Among middleage adults (30-59 years), the prevalence of overweight (BMI 25.1-30.0) and obesity (BMI > 30) was alarmingly high. The combined percentage of the two categories amounted to 55.1 percent in 2000. Moreover, a steady shift from the overweight to the obese category is observed. There seems to be little indication of undernutrition in this group, since the prevalence of underweight in adults aged 30 and more years was constantly low.

The most severe problems of overweight were in older Russians, aged 60 and above. The combined percentage of overweight and obese individuals in this age range was 68.2 percent. Moreover, there was a marked rise in obesity from 22.8 percent in 1992 to 32.6 percent in 2000. It is difficult to reconcile this pattern with the stereotype of the elderly as a relatively poor group within the population. In fact, the elderly have traditionally fared better economically than the rest of the population (Zohoori, Gleiter and Popkin, 2001), and the increase in overweight may be connected with the better-off position of this age group, even in the face of generally declining incomes.

There are significant differences in the incidence of underweight and obesity by sex, according to RLMS data. The incidence of underweight in young women is quite high, and that of obesity is quite a bit higher in women. Table 27 shows the proportions of women and men in the underweight, normal weight, overweight and obese categories in 1996. Among young adults, the prevalence of underweight is more than four times higher in females than in males. The slightly elevated prevalence of underweight in this age group as compared to older adults can be traced back to undernutrition of young women. The prevalence of overweight is similar for both sexes, but obesity is found two to almost three times more often in females. Among the elderly, 73.8 percent of women are overweight or obese, but only 53.8 percent of men. The share of individuals with normal body weight is higher among males for all age groups (Baturin, 2001).

FIGURE 15
Adult nutritional state (60 and more years)

Source: Zohoori, Gleiter and Popkin (2001).

TABLE 27
Women’s and men’s nutritional state in 1996, by age category

Source: Baturin (2001) (based on RLMS data).

Indicators of micronutrient deficiencies

Nationally representative data of micronutrient deficiencies are scarce, and the Russian Federation is no exception in this respect. Recent studies, however, indicate that the majority of the Russian population (adults and children) is deficient in iodine (up to 70 percent). Micronutrient deficiencies carry significant risks of morbidity and/or premature mortality.

Vitamins

The results of surveys conducted among schoolchildren, teenagers and industrial workers in selected regions of Russia indicate a lowering of the vitamin status during the reform period.^[22] Whereas the percentage of schoolchildren with Vitamin C deficiency in Yekaterinburg, Ufa, Norilsk and Yoshkar-Ola amounted to 48 percent in 1983-88, it increased to 63 percent in 1990-93. During the same period, the share of schoolchildren with severe Vitamin C deficiency rose from 2 percent to 23 percent. The percentage of children with a deficiency of the vitamins B1, B2, B6 and B12 in these regions doubled. Surveys carried out among children in Moscow reveal that the prevalence of various vitamin deficiencies was still high towards the end of the 1990s (Table 28). The situation was even worse for students of vocational schools in Yoshkar-Ola in December 1991. Ninety percent of the students suffered from a lack of Vitamin C, with 33 percent having a severe deficiency, and 70-75 percent of students were deficient in the vitamins B1, B2 and carotene (Baturin, 2001).

The vitamin status of adults also gives rise to concern. In the summer of 1990, the percentage of industrial workers in the Urals with severe vitamin C deficiency was 56 percent, a number that increased to 72 percent in 1992. The prevalence of severe Vitamin B1 deficiency among this population group rose from 20 to 56 percent, and that of severe vitamin B2 deficiency from 16 to 38 percent. The severity of vitamin deficiencies is usually higher in winter and spring, but inadequate vitamin status is also widespread during the more favourable summer season, as the above figures indicate. A considerable share of the working age population in Moscow was affected by lack of vitamins in the years 1996-1998 (Table 29) (Baturin, 2001).

TABLE 28
Vitamin deficiencies in children in Moscow

Source: Baturin (2001).

TABLE 29
Vitamin deficiencies in the working age population of Moscow

Source: Baturin (2001).

Minerals

Comprehensive data collected about iron deficiency anaemia in the Russian Federation indicate that anaemia is quite prevalent in infants aged six to twelve months and in young women. In surveys conducted in Moscow, Moscow Oblast, St. Petersburg and Sverdlovsk Oblast, iron deficiency anaemia was diagnosed in 15-47 percent of 6-12-month-old children. In Ivanovo Oblast, a relatively high prevalence of anaemia according to the haemoglobin level in the blood was found among children aged one to six years. The results of the survey carried out in autumn 1998 are shown in Figure 16 for different population groups (Baturin, 2001).

In addition to young children, pregnant and lactating women are very vulnerable to iron deficiency (Figure 16). According to official statistics released by the Ministry of Health, anaemia in pregnant women and women in labour has increased significantly in recent years (Figure 17). In 1996, anaemia was diagnosed in 25 percent of pregnant women and over 30 percent of pregnant women in the third trimester of pregnancy.^[23] There has also been a marked increase of women in maternity clinics treated for anaemia as a postnatal complication (Figure 17). A slight rise from 2.7 percent to 6.5 percent took place between 1985 and 1990, followed by a dramatic increase to 23.1 percent in 1996 (Baturin, 2001).

FIGURE 16
Prevalence of iron deficiency anaemia in Ivanovo Oblast, by population group, 1998

Source: Author presentation based on data from Baturin (2001).

Comparison with nutritional indicators in other countries

Stunting in infants and overweight in adults in Russia are quite high by world standards (Figure 18 and Figure 19). The incidence of stunting in infants is not only high compared to its incidence in older children, but compared to other countries. Likewise, the incidence in the Russian Federation of overweight is not only high compared with underweight, but also in international comparison.

For an international comparison of wasting and stunting prevalence in children, all countries in transition for which anthropometric data are available were selected together with the United States (as a representative of western industrialized nations^[24]) and some developing countries. Developing countries with the worst child anthropometric indicators, and poor performance in food security and nutrition in general, were chosen to represent the lower boundary of women in maternity clinics treated for anaemia after delivery child undernutrition. Additionally, a few developing countries that are relatively well off and show similar or more favourable wasting and stunting prevalence rates than the Russian Federation were also included (Figure 18).

FIGURE 17
Share of women in maternity clinics treated for postnatal anaemia in the period 1985-1996

Source: Author presentation based on data from Russian Ministry of Health 1996 (from Baturin, 2001).

The most likely reason for the comparatively high incidence of stunting in infants is a “weaning crisis”, an outcome of improper complementary feeding during infancy and associated health problems. Generally, infants’ nutritional status is protected by breastfeeding. Stunting usually peaks either in the age group of one- to two-year-olds or rises successively up to age five or beyond.^[25] The pattern in the Russian Federation is obviously quite different, which suggests examination of infant feeding practices and health problems. The opportunities for such an investigation are limited due to lack of comprehensive and nationally representative studies of infant feeding. The Czech Republic is the only country beside the Russian Federation in the selected country set with the share of stunted infants exceeding the prevalence of stunting in the total group of under-five-year-olds. Yet the difference of prevalence rates in the Czech Republic between infants and pre-schoolers is only 1.6 percentage points, whereas it is 9.0 percentage points in the Russian Federation.

FIGURE 18
Prevalence of stunting and wasting in preschool children in selected countries (data from period 1990-2000)

Source: Author presentation based on data from WHO (2002); Note: RF = Russian Federation.

Russian pre-school children are also at a high risk for wasting (low weight for height). The Russian Federation is ranked at the upper end of the spectrum.^[26] Whereas some other countries in transition have a lower prevalence of wasting (Kazakhstan, the Czech Republic, former Yugoslavia, Georgia, Romania, the Kyrgyz Republic and Armenia), the situation is worse in Albania, Azerbaijan and Uzbekistan.

Perhaps the most striking ranking of the Russian Federation in world comparison is that for underweight and overweight (Figure 19). In 1993 the country had a lower incidence of underweight population than even some Western European countries - the United Kingdom and Sweden - let alone developing countries such as China and India. But the incidence of overweight was one of the highest in the world: higher than in the United Kingdom which has significantly higher income per capita.

The world ranking of the Russian Federation in regard to mineral deficiencies seems to be worse for iodine deficiency than for anaemia (iron deficiency). Lack of iodine is the second most prevalent micronutrient deficiency in the world, affecting about one-third of the world population (WHO/UNICEF/ICCIDD, 1999). The exact prevalence in the Russian Federation is not known, yet the majority of the population (up to 70 percent) is supposed to be subject to iodine deficiency. Iron deficiency anaemia is a matter of concern for more than half of the world population (UNICEF/UNU/WHO/MI, 1999). Taking anaemia in pregnant women as a yardstick, the Russian Federation is still quite well off with a prevalence of 25 percent. In India, for example, 88 percent of pregnant women suffer from anaemia. In contrast, Poland is at the opposite end of the spectrum with a prevalence rate of 16 percent (World Bank, 1997). In the European Union, about 22 percent of pregnant women are anaemic (WHO, 2000a).

Anthropometric indicators and poverty

Food insecurity and poverty are usually closely related. It was shown in the last chapter that the probability of family undernutrition is highly correlated with total income in the Russian Federation. What about anthropometric indicators of food insecurity? A number of cross-country studies have established a significant correlation between indicators of undernutrition and per capita or per household income. Anthropometric outcomes of both children and adults are expected to be influenced by the level of family income in a number of ways. First, absolute poverty is likely to prevent people from disposing of sufficient amounts of food, either from purchases on the market or home production. Second, anthropometric status is not only an outcome of food intake, but also determined by health status. Poor health may depress appetite and impede children’s growth, and acute infections frequently result in wasting. A family’s ability to seek health care in the case of illness depends on its financial resources. Third, family income is expected to be related to living conditions, with poor families living in less healthy environments (with respect to sanitation, safe water and housing) and thus being more exposed to pathogens.

FIGURE 19
Percentage of population overweight and underweight in selected countries (1993)

Source: WHO (1998b).

RLMS anthropometric data for 727 children up to seven years and 8 217 adults aged 18 years and over (RLMS, 2002) indicate very little correlation between income and underweight in the Russian Federation, except for boys aged 0 to 7. The same data show a fairly strong correlation between overweight and income group. The incidence of overweight rises with income levels. The surprising lack of correlation for underweight could be explained by less divergence within the Russian population in sanitation conditions, access to safe water, basic medical care, food intake and housing conditions than in developing and developed countries.

FIGURE 20
Nutritional state of girls, by poverty group

Source: Author’s calculations using RLMS (2002).

FIGURE 21
Nutritional state of boys, by poverty group

Source: Author’s calculations using RLMS (2002).

Children

Children are more vulnerable to nutritional deficiencies, infectious diseases and poor living conditions than adults. Stunting in particular as an indicator of poor growth is supposed to be closely correlated to poverty, and this form of child undernutrition gives rise to concern in the Russian Federation. Figure 20 and Figure 21 show girls’ and boys’ nutritional status by poverty group; the first two groups are classified as poor, the latter three as non-poor.^[27] Poverty and anthropometric outcomes seem relatively unrelated for girls, since there are high prevalence rates of stunting and wasting in group 4 from relatively well-off families. For some unknown reason, a quite high share of girls in group 4 (4.3 percent as compared to 0 percent in the other groups) is both wasted and stunted.

The picture for boys is closer to the expected, particularly with respect to stunting. Among boys in the poorest families, 12.1 percent are stunted, but only 3.1 percent of male children in the wealthiest group are stunted. The association of poverty level and wasting is less clear, yet this is not surprising, since the weight-for-height indicator for children reacts more quickly to short-term changes such as infections. Thus, it may be more confounded by conditions that are not adequately captured in the survey data.

Adults

Undernutrition in adults is not very prevalent (see Figures 13, 14 and 15 and the international comparison in Figure 19). Yet, poverty has been hypothesized to cause underweight among adults. Economic inequality is supposed to have increased during the reform process, raising concerns about a possible deterioration of nutritional status among the poor. There is indeed a slight tendency of decreasing underweight from the poorest to the wealthiest group, especially among females (Figure 22 and Figure 23). However, the declining share of adults with normal body weight and the considerable rise in overweight and obesity among women with rising incomes is quite a bit more pronounced.

FIGURE 22
Nutritional state of women, by poverty group

Source: Author’s calculations using RLMS (2002).

FIGURE 23
Nutritional state of men, by poverty group

Source: Author’s calculations using RLMS (2002).

Overnutrition according to the BMI measure is obviously not only a problem of the wealthier segments of the population, but also affects the poor to a considerable extent, much more than undernutrition. It is the magnitude that increases with gains in income. The correlation of age with total income per household member may contribute to this appearance, since overweight and obesity are most prevalent among the elderly, who are better off in economic terms than younger people.

Public health and diet in the Russian Federation

In contrast to Japan, the United States, the European Union, eastern Europe and other developed countries, a marked reduction in life expectancy was observed in the Russian Federation and other successor states of the Soviet Union in the 1990s (Figure 24). This is a unique phenomenon in major industrial nations to date. By 1998, three years of average life expectancy had been regained as compared to 1994, yet the figure was still about two years below the highest level achieved in the Soviet period (in 1987).

A number of explanations have been proposed for the shortening of life expectancy: increased alcohol consumption, food consumption/dietary intake, and the social and economic stratification of the population during the reform process (WHO, 2000a). The balance of evidence cited in the following discussion suggests that the main reason for the decline in life expectancy was an increase in mortality, particularly between 1986 and 1994 and particularly for adults. The primary causes of this increase in mortality were increases in deaths from “external causes” (e.g. accidents, poisoning, homicide and suicide) and from cardio-vascular diseases (CVD). Increased alcohol consumption over this period seems to have been a prime cause of deaths via these two avenues (WHO, 1999). Additionally, the Russian population was subjected to higher levels of stress during the end of the Soviet period and early transition years, a non-nutritional risk factor of hypertension and myocardial infarction. The difficulty of the period is underlined by increases in the numbers of people diagnosed for the first time with mental disorders from 1992 to 1994 (WHO, 1999).

Though the mortality crisis of the early nineties cannot be attributed to food consumption patterns and nutritional state, the death rates from circulatory diseases standardized for age in the Russian Federation are quite high compared with other countries. Food consumption patterns and nutritional state definitely are primary causes of elevated mortality rates from CVD, since obesity and overweight make it more likely that CVD will result in death. In other words, though the sudden decrease in life expectancy of the early 1990s cannot be attributed to nutritional state as an immediate cause, the Russian population, because of its risky nutritional state - with high rates of overweight and obesity and high prevalence of hypertension among adults - is more likely to die once CVD is diagnosed than the population in most other countries. Primary reasons for this risky state are overnutrition and lack of exercise, perhaps combined with lower levels of medical care.

FIGURE 24
Life expectancy in the Russian Federation, other NIS, four eastern European countries, Japan and the United States (1980-98)

Source: Author presentation based on data from World Bank (2000).

Nutrition and health

In order to better understand the role of nutrition in disease outcomes, it may be helpful to review some of the chief diseases associated with dietary deficiencies or excesses (Table 30). Practically every organ and system in the human body depends on nutrition for its normal functioning. Both inadequate and excessive intakes of nutrients are harmful to health, and the paths of disease causation are manifold.

Whereas lack of micronutrients is associated with specific deficiency diseases, other health problems like obesity are solely caused by excess dietary intakes relative to requirements. The list of diseases arising from excessive alcohol consumption is necessarily incomplete, as alcohol can damage almost every organ due to its toxic metabolism, and may also cause micronutrient deficiencies. Hypertension, obesity, and diabetes mellitus are caused by, or at least influenced by, nutritional excess, and all three are independent risk factors for heart disease. High blood levels of lipids further increase the risk of atherosclerosis and consequently cardiovascular and cerebrovascular diseases (e.g. myocardial infarction and other ischemic heart diseases, stroke). Yet there is a range of nutrients that are supposed to exert a protective effect on the circulatory system: unsaturated fatty acids and antioxidants in vegetables and fruit, including vitamins C and E. This means, however, that excess intakes of saturated fats are even more harmful in the presence of deficiencies of protective substances. In addition, recent research has revealed that foetal undernutrition and micro-nutrient deficiencies during pregnancy are not only risk factors of low birth weight and birth defects, but may induce obesity and a range of adverse hormonal changes in later life. Nutritional deficiencies during pregnancy and infancy increase the susceptibility to a variety of chronic diseases in adulthood, such as diabetes and cardio-vascular diseases (Popkin, Richards and Montiero, 1996).

TABLE 30
Effects of nutrition on human health

Source: Adapted from WHO (2000a)

Trends and determinants of mortality patterns

The peculiar pattern of decline and then increase in life expectancy of Figure 24 must be associated with an increase and then decline in mortality rates for one or more segments of the population. Moreover, to understand whether the mortality change is connected with diet, changes in mortality from the main causes of death must be considered. Table 30 can assist in understanding which diseases (causes of death) are associated with dietary deficiencies or excesses.

Mortality rates for infants and children do not follow the required pattern of rise and then fall. For this reason, it is doubtful that changes in infant and child mortality are associated with the changes in life expectancy of Figure 24. Moreover, the changes in infant and child mortality do not follow a similar pattern to the trend in child undernutrition (stunting and wasting). The survival chances of infants have continuously improved in the Russian Federation during the last ten years, and the mortality rate for children aged 0-14 years fell from 1987 to 1997 (WHO, 1999). At least in this crude aggregate consideration, there is no association of the peak in child malnutrition in 1994 (compare Figure 11 and Figure 12) and infant mortality. The negative trend in child undernutrition during the years 1992-1994, then, cannot explain the decline of life expectancy.

For the Russian population aged 0-64 years, CVD, “external causes” (e.g. accidents, poisoning, homicide and suicide) and cancer - listed in order of importance - are the major killers. In 1998, these three categories accounted for 78.3 percent of total mortality in the respective age group.^[28] Other causes of death such as infectious and parasitic diseases (including tuberculosis, diphtheria and sexually transmitted diseases) play only a minor role in comparison to chronic life-style related diseases: they accounted for only 3.1 percent of deaths among 0-64 year-olds and for 0.3 percent of deaths among the elderly in 1998 (WHO, 1999). Moreover, the pattern of changes in mortality from infectious and parasitic diseases does not fit the pattern in Figure 24. Mortality from infectious and parasitic diseases almost doubled during the period 1991-1996 according to age-standardized death rates (SDR) (WHO, 1999). The rise of underweight prevalence among young adults may have contributed to this trend, but it is doubtful that the significant changes in life expectancy in Figure 24 can be attributed to the rise in mortality from infectious and parasitic diseases, since 97 percent of deaths were due to other reasons.

Careful study of the three main causes of mortality in the Russian population indicates that cardio-vascular disease and external causes are the most likely causes of the fall in life expectancy observed in Figure 24. Mortality from cancer was only very slightly elevated in 1994 as compared to the beginning of the 1980s and declined again from 1995 on (WHO, 1999). Thus, the sharp fall in life expectancy cannot be mainly attributed to deaths from cancer and nutrition-related causes of cancer. In contrast, the trends in mortality from cardiovascular diseases and external causes developed nearly in parallel since 1984 and show a marked peak in 1994, when life expectancy reached its lowest point. The age-standardized death rate from CVD was almost twice as high in 1994 as in 1986, and mortality from external causes more than doubled during the seven years following 1987. From 1995 on, the negative trend in both mortality rates was reversed (WHO, 1999).

There is a strong association of mortality from external causes and variations in alcohol consumption and no reason to suspect a link with food consumption. Alcohol abuse, then, is quite likely an important cause of the decline in life expectancy in Figure 24. An initial decline of mortality from external causes followed President Gorbachev’s anti-alcohol campaign in 1985-1986. After the bans introduced during the campaign were lifted in 1987, alcohol consumption increased sharply, and mortality rates from external causes gradually rose until 1992. From 1992 to 1994, the situation worsened due to the negative impact of the reform process while alcohol prices increased much more slowly than the prices of other consumer goods, including foodstuffs (WHO, 1999). According to data collected in the RLMS, the per capita alcohol consumption of adult males increased by 50 percent from 1992 to 1994, and then declined again by 1998 to the level in the first survey round (Zohoori, Gleiter and Popkin, 2001).^[29] From 1988 to 1994, the incidence of alcoholic psychosis increased ten-fold, but fell by 34 percent from 1994 to 1997.

The role of high alcohol intakes in cases of injury and poisoning is underscored by the fact that the share of alcohol poisoning in deaths from external causes was 12.5 percent in 1995 and exceeded the proportion of traffic accidents (11.1 percent). A significant number of accidents of undetermined cause, accidental falls, drowning and other accidents (41 percent of deaths from external causes) were also related to alcohol consumption. The age-standardized death rates (SDRs) from homicide, suicide and self-inflicted injury accounted for one-third of the total SDR from external causes in 1997. They followed the same trend as the total mortality rate from external causes, with the lowest level reached in 1986 towards the end of the anti-alcohol campaign, and a considerable peak in 1994, when alcohol consumption reached its maximum (WHO, 1999).

Changes in alcohol consumption are a major reason for changes in mortality from cardio-vascular diseases as well (WHO, 1999). This is quite plausible, because alcohol abuse tends to increase hypertension and induce a high concentration of triglycerides (fats) in the blood, which are both risk factors of cardiovascular diseases. Moreover, between 1984 and 1998, mortality from CVD follows exactly the same trend as total mortality from external causes, suicide and homicide, with the lowest level reached in 1986 and a subsequent steep rise until 1994.

Additionally, the Russian population seems to have undergone considerable distress during the early transition period, which is a non-nutritional risk factor of hypertension and myocardial infarction. Apart from augmented drinking and substance abuse, the rapid increases in the numbers of people diagnosed for the first time with mental disorders from 1992 to 1994 point to the climate of insecurity during the social and economic upheaval (WHO, 1999). In 1994, there was not only a health crisis as evidenced from the peak in mortality rates and the unprecedented fall in life expectancy, but the first period of hyperinflation in the Russian Federation in the 1990s (Mroz, Henderson and Popkin, 2001; Popkin, Zohoori and Baturin, 1996).

Whereas the changes in mortality from CVD since the mid-1980s are unlikely to have arisen from altered food consumption patterns and nutritional status, death rates from circulatory diseases standardized for age in the Russian Federation are quite high compared with other countries. WHO provides comprehensive statistics on SDR by causes of death for 46 countries, including western industrialized countries, 20 countries in transition and four quite advanced developing countries (WHO, 1999). The bottom nine places from all causes according to the SDR are held by countries in transition, including the Russian Federation (Figure 25), and almost the same picture emerges for mortality from diseases of the circulatory system, which are predominantly cardiovascular diseases (Figure 26). The high contribution of these diseases to overall mortality in countries in transition is evident from Figure 27, which shows the share of diseases of the circulatory system in the SDR from all causes. Furthermore, CVD were the main cause of disability in the Russian Federation in 1997, accounting for 48 percent of all new cases of disability (WHO, 1999).

FIGURE 25
Age-standardized death rates from all causes of death (per 100 000 of the standard population)

Source: Author presentation based on data from WHO (1999).

FIGURE 26
Age-standardized death rates for diseases of the circulatory system, including ischemic heart diseases and cerebrovascular diseases (per 100 000 of the standard population)

Source: Author presentation based on data from WHO (1999).

The Russian population, because of its risky nutritional state - with high rates of overweight and obesity and high prevalence of hypertension among adults - is more likely to die once CVD is diagnosed than the population in most other countries. The dietary habits of the Russian population (as well as lack of exercise and lower levels of medical care) are primary causal factors behind these problems. The high rates of overweight and obesity in Russian adults were illustrated in Figure 19. Hypertension is found in 60 percent of men and 34 percent to 51 percent of women (according to the “hard” criteria of blood pressure being 140/90 mm Hg). Elevated total serum cholesterol levels were diagnosed among 21.3 percent of men and among 17.8 percent of women aged 20-59 years (WHO, 1999). All these risk factors - overweight and obesity, hypertension, high serum cholesterol levels - are partly or mainly determined by dietary intakes. This also holds for widespread polyhypovitaminosis stated earlier, which is likely to aggravate the problem (Table 30). Russian patterns of food consumption, then, are a chief cause of the high prevalence of nutritionrelated risk factors.

FIGURE 27
Deaths from diseases of the circulatory system expressed in percentage of deaths from all causes (in age-standardized death rates)

Source: Author presentation based on data from WHO (1999).

Dietary intakes

The majority of the most severe nutritional problems in the Russian Federation - overweight and obesity in adults and various micronutrient deficiencies in both adults and children - are linked to the Russian diet. The following section highlights facets of the Russian diet that are responsible for these problems. For children, these are low rates of breastfeeding, deficiencies in weaning practices, apparent overnutrition for years 0 to 7 and undernutrition from 7 to 13, a lack of vitamin C and iron deficiencies. For adults, the most severe problems are caused by a high-fat, low fibre diet. This includes low consumption of fruits and vegetables (a low-fibre diet), high consumption of meat and meat products (with a high fat content) and higher than recommended alcohol (for males) and sugar consumption.

Children

Breastmilk is the optimal food for infants throughout the first six months of life. Breastfeeding ensures optimal growth and development of the baby and protection against infection. However, the prevalence of breastfeeding in the Russian Federation is low in the age group of 0-6 months and has even declined in recent years (Table 31) (WHO 2000a).

Even among infants of up to three months, only around 42 percent were exclusively breastfed in 1999. One of the reasons for low breastfeeding rates is the current practice of infant care management and feeding recommendations. Health professionals working in the sani-eped centres^[30] advise the separation of mothers and newborns in maternity clinics. This practice is still widely believed to prevent the transfer of infection from mothers to babies. However, the opposite is true: the separation of mothers and infants is an obstacle to successful breastfeeding, thereby making babies more susceptible to infection. Furthermore, the hygienists of the sani-eped service warn of breastfeeding because breastmilk is supposed to contain high concentrations of PCBs (polychlorinated biphenyls) (WHO, 1998a). Yet the benefits of exclusive breastfeeding in the first half of the first year of life still outweigh possible disadvantages from environmental contamination.

TABLE 31
Prevalance of breastfeeding

Source: WHO (2000a)

Little information is available on weaning practices and complementary feeding. A survey on food consumption, nutrition and health status was conducted among 4 000 poor families in selected oblasts (Volgograd, Voronezh, Samara and Pskov) and the Republic of Komi. These survey findings are neither statistically representative for the total population of the Russian Federation, nor for the group of poor households in all geographical regions. However, if they reflect common practice, they indicate a considerable lack of knowledge of proper weaning practices. Whereas the majority of neonates in the sample population received breastmilk, 14.7 percent of infants that were not breastfed received cow milk as first food instead of adapted formulas (Baturin, 2001). Unmodified, pure cow milk is considered inadequate for children younger than nine months (WHO, 2000). Yet cow milk was offered to more than half of the infants before the age of four months, especially in the lowest income families. In the higher income group among these poor households, porridge was prepared from commercial products tailored to infants’ needs, but this was not the case for families with lower incomes, who used ordinary, non-fortified ingredients to make porridge for infant feeding (Baturin, 2001).

Information on infant feeding practices in the Russian Federation (WHO, 2000b) allows conclusions to be made concerning the reasons for the observed disturbing pattern of extremely high rates of stunting among children less than one year of age. Too early introduction of tea, cow milk and solids to a large proportion of infants (displacing breast milk and causing iron deficiencies) and inadequate complementary feeding (too late introduction of meat and liver) are clear causes of stunting. Such practices are responsible for the coexistence of an oversupply of calories with micronutrient deficiencies.

However, RLMS data supports the hypothesis that stunting in the age group of under-fives arises from causes other than deficits in dietary energy consumption, such as micronutrient deficiencies and possibly frequent infection. Detailed data on dietary intakes of preschool and school-age children have been collected for a nationally representative sample in the RLMS rounds

TABLE 32
Intakes of dietary energy, fat, protein and vitamin C among children aged 0-13 years, 1992-93

Note: Required and recommended intakes are taken from United States Recommended Daily Allowances (NRC, 1989).

Source: Adapted from Tseng et al. (1997) (based on RLMS data).

by means of the 24-hour-recall method. Using this information, Tseng et al. (1997) calculated dietary energy, fat, protein and Vitamin C intakes for children aged 0-6 and 7-13 years as well as bioavailability of dietary iron (Table 32 and Table 33).

These data suggest that stunting in the age group of under-fives probably does not arise from deficits in dietary energy consumption. Mean dietary energy intakes of children aged 0-6 years are above the upper limit of requirements in 1992-93, and the threshold level of the 75th percentile exceeds this limit considerably, by more than 300 kcal. There is no indication of a lack of protein in the diet of children aged 0-13 years: protein accounts for 16 percent of total calorie consumption and the absolute amounts are well above the recommendations for the different age groups. The fat content of the diet ranges from 36 to 38 percent of dietary energy intake. The recommended amount for children up to two years is 30-40 percent to avoid both a diet too high in fat and too low in energy density. For older children, the figures suggest mean energy intakes below requirements.^[31]

TABLE 33
Intake of bioavailable iron among children aged 0-13 years, 1992-93

Source: Adapted from Tseng et al. (1997) (based on RLMS data).

Existing studies suggest that Russian children suffer from vitamin C and iron deficiencies. Consumption of vitamin C in the Tseng et al. (1997) sample was quite low compared to United States recommended levels. If vitamin C intake is compared with German recommendations for child consumption of vitamin C (lower than the United States recommendations and range from 40 mg for infants aged 0-2 months to 70mg for 10-12-year-olds), the picture looks better for preschool children. Yet iron intakes are consistently below the lower boundary of requirements for growth and maintenance if bioavailability is considered^[32] (Table 33); this is in line with the findings on iron deficiency anaemia in children presented earlier in this chapter. Iron absorption is higher for heme than for non-heme iron, and the bioavailability of non-heme iron is enhanced in the presence of heme iron from meat or vitamin C, whereas phytate and black tea act as inhibitors. Since tea is consumed with every meal and phytate intakes are high, average bioavailability of total iron is estimated to be only 3-4 percent. This is considerably below the assumed absorption of iron of 10 percent that usually serves as a base for recommendations on desirable dietary intakes of total iron (Tseng et al., 1997).

Surveys of Moscow schoolchildren indicate that Russian schools provide meals low in calcium, riboflavin and vitamin C. Repeated surveys of schoolchildren from 10-15 years of age were conducted in Moscow in the years 1992-95 using the 24-hour-recall method. These studies show that the most frequently eaten food items were bread and other cereal-based foodstuffs, meat and meat products, sugar and confectionery. Fresh fruit and vegetables, fish, eggs, milk and cheese were rarely consumed. The intakes of calcium and riboflavin were apparently low in comparison to the recommendations, which can be traced back to low consumption of milk and milk products (Martinchik, Baturin and Helsing, 1997).

TABLE 34
Food consumption based on Goskomstat household surveys in the Russian Federation, 1980-1999

Sources: Goskomstat (1999b), pp. 167-168; Goskomstat (2001a), pp. 19, 24.

Average dietary intake of the Russian population

For the Russian population as a whole, on average no deficits in calorie and macronutrient consumption during the transition years were found. The average diet of Russians has become healthier since 1990 due to decreases in milk, meat and fat consumption and a rising share of starchy staples like bread and potatoes. But low consumption of vegetables and fruits are responsible for a number of vitamin deficiencies. Moreover, continued high consumption of meat and meat products is responsible for high fat consumption, with resulting cardio-vascular disease problems for the population as a whole.

Table 34 shows official Goskomstat figures on per capita food consumption by food group from household surveys for all households, along with the nutritional equivalents in terms of calories, proteins, fats and carbohydrates. The increasing share of dietary energy from vegetable sources corresponds to commonly-accepted dietary guidelines (WHO, 2000a). Protein intakes are still in the range of recommended levels, both with respect to absolute consumption per capita and day and with reference to their share in total calories. Fat consumption has moved closer to the intakes that are conducive for health, though these numbers are still relatively high. The percentage of dietary energy from fat should not exceed 30 percent (WHO, 2000a).

The figures on consumption of meat and meat products (in terms of meat) and milk and dairy products (in terms of milk) per capita illustrate the effects of policy on diets, just as the fall in these two measures illustrates the effects of reforms. Figure 28 and Figure 29 show trends in food consumption between 1980 and 1999. In the pre-reform period, milk and meat were heavily subsidized, so that Russians could afford to consume these foodstuffs in large amounts (Popkin et al., 1997b). The rationale behind this policy was the erroneous belief that large amounts of calories and animal protein were necessary to prevent malnutrition. This erroneous belief was based on grossly overstated requirement estimates (Popkin et al., 1997a). During the reform period, subsidies were reduced, followed by increased prices of animal products. In contrast, the downward trend in bread and potato consumption was reversed in 1990, whereas the intakes of vegetables and fruit, sugar and confectionery have continued to fall. Fish and vegetable oil are still among the less preferred foodstuffs.

FIGURE 28
Changes in animal product consumption in the Russian Federation, 1980-1999

Source: Table 34.

FIGURE 29 Changes in vegetable product consumption in the Russian Federation, 1980-1999

Source: Table 34.

TABLE 35
Actual and recommended average dietary intakes in the Russian Federation, 1990-91, 1998-99¹

¹ Mean of the two years

² Based on RLMS data from 2000

³ Calculated from a recommended intake of ca. 400 g potatoes or 75-90 g rice or pasta and 250-300 g bread

⁴ More than 400 g vegetables and fruit according to WHO recommendations

⁵ No more than 80 g red meat according to WHO recommendations

⁶ Calculated from a recommended intake of 250 g low-fat milk and 60 g cheese

⁷ Based on a dietary energy intake of 2 200 kcal/capita/day (no more than 10% of calories should originate from sugar)

⁸ WHO recommendation

Source: Author’s calculations based on data from Goskomstat (1999b), pp. 167-168; Goskomstat (2001a), pp. 19, 24; Zohoori et al. (2001), p. 3; WHO (2000a), pp. 6f, 15; and Pölert and Löhlein (1995), p. 470.

Table 35, actual intakes of different foodstuffs in 1990-91^[33] and 1998-99 and alcohol in 2000 are contrasted with recommended levels. The increased consumption of bread and cereal-based foods and potatoes as well as the decline in meat consumption are positive trends, because their intakes have moved closer to recommended amounts. However, the consumption of meat and meat products, which are major sources of saturated fat that increase the risk of cardio-vascular disease (CVD), is still considerably above recommended levels (according to both German and WHO recommendations). As eggs and fullfat milk have relatively large cholesterol contents, falling intakes since 1990 likewise constitute a positive trend, although milk consumption had reached quite a low level by 1998-99.^[34]

The decline in the consumption of vegetables and fruit is definitely negative, since their intakes ranged already far below recommended levels in 1990-1991 (WHO, 2000a). This unfavourable trend can be held responsible for widespread vitamin deficiencies. In contrast, the consumption of sugar and alcohol (empty calories, without nutritional value), though it declined since the peak in 1994, is still above recommended maximum levels.^[35]

To summarize the evidence on diet: for the population as a whole, nutritional excess seems to be a far greater threat to public health than deficits in dietary energy. Considering the fact that mortality in the poorer developing countries (for which WHO provides no age-standardized death rates) is mostly a matter of infectious and parasitic diseases and not due to non-communicable diseases, the successor states of the former Soviet Union probably hold the international record in mortality from diseases of the circulatory system. They are closely followed by the transition countries in eastern Europe (WHO, 1999). The high share of cardiovascular diseases can be traced back to nutrition-related risk factors like hypertension, obesity and high serum cholesterol levels that are in turn outcomes of excess intakes of dietary energy, saturated fats, cholesterol and alcohol (WHO, 1999). The traditional Russian diet implies high intakes of meat and milk (including their products) and animal fats, which is a legacy of the Soviet era, when those products were heavily subsidized and erroneous recommendations created erroneous beliefs among health professionals and the general public about nutritional needs.

Against this background, many Russians perceive the reduction in meat and milk consumption that followed the economic reforms and cutback of subsidies as impending malnutrition. Yet, from the viewpoint of healthy eating, the decreased consumption of animal products and fat means an improvement of the average Russian diet. Unfortunately, dietary intakes of fresh fruit and vegetables have fallen even more below recommended levels since 1990, which is a negative trend. Poor knowledge of the principles of healthy eating, unfavourable food preferences and attitudes towards breastfeeding, as well as low levels of physical activity, have been identified as major obstacles to improved nutrition and health in the Russian Federation.