IDENTIFICATION OF DISTRICTS AT RISK OF NUTRIENT-RELATED DISEASES BASED ON THE LOCAL DIET

Проблема роста уровня алиментарно-зависимых заболеваний в настоящее время имеет глобальные масштабы. Целью исследования были изучение уровня потребления основных продуктов питания и оценка показателей алиментарнозависимых заболеваний населения Воронежской области. Баланс потребления продуктов питания изучали по данным территориального управления Росстата по Воронежской области за два пятилетних периода (1995–1999 гг. и 2012–2016 гг.). Анализ алиментарно-зависимой заболеваемости выполняли по данным обращаемости населения за медицинской помощью с последующим ранжированием показателей на отдельных территориях на пять уровней. За два пятилетних периода произошли существенные изменения в характере питания: увеличилось потребление в расчете на одного жителя рыбопродуктов, свежих фруктов, мяса и мясных продуктов, овощей и бахчевых, яиц, растительного масла, молока и молочных продуктов. Вместе с тем наблюдается избыточное потребление сахара, хлебных продуктов, картофеля — от 1,42 до 2,04 раз, что свидетельствует о преобладании в рационе углеводной составляющей. По результатам оценки, отмечается достоверное увеличение показателей заболеваемости ожирением до 4,5 раз, анемией, болезнями эндокринной системы (в 1,8–2 раза) и болезнями органов пищеварения (в 1,2 раза). Приоритеты в профилактике алиментарно-зависимой заболеваемости должны быть отданы территориям риска.

. Consumption of staple foods in Voronezh region in 1995-1999 and 2012-2016 (per one person, kg/year)
Nutrient-related morbidity varies across different Russian regions, necessitating research into regional nutritional patterns [9,10]. Regional studies will help to elaborate measures aimed at providing the population with a balanced diet, ensuring adequate food quality control and preventing nutrient-related diseases [11].
The aim of this work was to study consumption of staple food products and assess the incidence of nutrient-related diseases in Voronezh region.

METHODS
The study was conducted in 32 districts of Voronezh region populated by 2.3 million people. Reports on the consumption of different food products collected over two 5-year periods (1995-1999 and 2012-2016) were provided by the local branch of the Federal State Statistics and reflected quantitative and qualitative changes in the consumption of 10 staple food categories: breads; potatoes; vegetables, melons and gourds; fresh fruits; sugar; meat; seafood and fish; milk and dairy products; eggs; vegetable oil. The data were compared with the values specified in the Recommended rational norms of food consumption that meet modern nutritional requirements (Order 614 of the Ministry of Health of the Russian Federation dated August 19, 2016).
The incidence of nutrient-related diseases was estimated from the data supplied by the Federal State Statistics Service (report form 12 providing information about the incidence of diseases registered in patients residing in healthcare service areas) collected from 1995 through 1999 and from 2012 through 2016. The data were analyzed in Statistica 6.0 and Microsoft Office (Excel).
To rank the average long-term incidence of nutrient-related diseases, we applied an algorithm determining the upper and lower values for this parameter based on its average value in the studied region (M) and mean square deviation (σ); the obtained data were distributed into 5 sets. Values falling into the first set were ranked as low (Mσ and lower); in the second set, below average (from Mσ to M -0.5σ); in the third set, average (from M -0.5σ to M + 0.5σ); in the fourth set, above average (from M + 0.5σ to M + σ); and in the fifth set, high (M + σ and above). Regions with high long-term incidence (rank 5) were considered to be at risk.

RESULTS
The analysis of data on the consumption of staple food products in Voronezh region in 1995-1999 and 2012-2016 revealed considerable changes in the diet of its population ( Table 1). Consumption of fish and seafood per one person (kg/year) increased 3.14-fold; fresh fruits, 2.0-fold; meat and dairy products, 1.93-fold; vegetables, melons and gourds, 1.63-fold; eggs, 1.44-fold; vegetable oil, 1.36-fold; milk and dairy products, 1.13-fold. At the same time, consumption of potatoes and breads slightly decreased, while sugar consumption remained stable (49 kg per 1 person a year).
The population of Voronezh region consume 2.04 times more sugar than is recommended and 1.42 times more bread. At the same time, their diet lacks high biological value foods, such as milk and dairy products (sour cream, butter, cottage cheese, cheese, kefir and yoghurt), constituting only 83% of the recommended amount (i.e., consumption of these products is 1.21 times lower than it should be). Being an important source of vitamins and minerals, vegetables included in the population diet, such as cabbages, carrots, beetroot, onions, tomatoes, cucumbers, bell peppers, courgettes, green salads, etc., constitute only 92% of the advised intake (their consumption is 1.8 times lower than the recommended amount); fresh fruits, such as apples, pears, grapes, and citrus fruits, make only 75% of the advised intake (their consumption is 1.33 times lower than the recommended amount). This leads us to conclude that the main component of the diet in Voronezh region is carbohydrates. Imbalanced diet and negative environmental factors increase the risk of nutrient-related diseases. When comparing their long-term incidence in the two studied 5-year periods, we established that incidence per 1,000 population had increased 1.2-4.5-fold for almost every class of nutrient-related diseases except for peptic ulcers. The most significant 4.5-fold increase was observed for obesity (Table 2).
Using the data that describe the average long-term incidence of nutrient-related diseases in Voronezh region, we built a 5-level scale to rank its districts accordingly (Table 3).
Long-term statistics collected over 2012-2016 demonstrated that the incidence rate of diseases affecting blood and hematopoietic organs was 17.1 ± 1.22 cases per 1,000 population; anemia was diagnosed in 3.7 ± 0.26 individuals per 1,000 population. On the whole, this pathology tended to increase in incidence (R 2 = 0.829). The same situation was observed in some relatively "healthy" districts belonging to rank 1 (0.6-2.2 cases per 1,000 population): Nizhnedevitsky district had 1.6 cases per 1,000 population (the incidence growth rate was 111.0%); Verkhnekhavsky district had 1.4 cases per 1,000 population (the growth rate was 241.6%); in Khokholsky district 1.4 cases per 1,000 population were registered (the growth rate was 295.7%); in Ternovsky district, 0.6 cases per 1,000 population (the growth rate was 83.0%). Among the districts at risk of anemia (rank 5, 4.7-6.8 cases per 1,000 population) were Bogucharsky, Verkhnemamonsky and Kalacheevsky, exhibiting a slower growth rate (minus 33.3%, 11.9% and 30.8%, respectively) and the highest incidence rates of 4.7, 6.3 and 6.8 cases per 1,000 population, respectively.
At present, the average long-term incidence of gastrointestinal diseases in Voronezh region is 97.4 ± 4.91 cases per 1,000 population showing a strong tendency to increase (R 2 = 0.927). Among the districts assigned to rank 5 on our scale (129.8-212.9 cases per 1,000 population) are Repievsky with 212.9 cases per 1,000 population, Povorinsky with 182.9 cases per 1,000 population and Talovsky with 172.1 cases per 1,000 population. The lowest incidence (rank 1, 46.1-54.7 cases per 1,000 population) was observed in Verkhnekhavinsky (46.1 cases per 1,000 population), Olkhovsky (52.9 cases per 1,000 population) and Ertilsky (53.5 cases per 1,000 population).
Comparison of the two studied 5-year periods revealed that the incidence rate of peptic ulcers tended to decrease from 15.5 ± 0.03 to 12.9 ± 0.13 cases per 1,000 population (which is by 17%). Nonetheless, 4 regions were still assigned to rank 5 (the highest incidence) based on the average longterm disease incidence (2012-2016): Kalacheevsky with 28.2 cases per 1,000 population, Talovsky with 21.8 cases per 1,000 population, Kantemirovsky with 21.7 cases per 1,000 population, and Ternovsky with 17.8 cases per 1,000 population. But on the whole, in spite of high long-term growth rates, the incidence is decreasing.
Districts with the lowest incidence rates assigned to rank 1 included Verkhnekhavsky, Nizhnedevitsky and Repievsky (6.7-8.5 cases per 1,000 population) and showed an alarming trend: they exhibited the highest growth rate of peptic ulcer incidence in 2012-2016 (63.93%, 68.04% and 139.04%, respectively).
The average incidence of gastritis and duodenitis in Voronezh region is 21.9 ± 1.1 cases per 1,000 population; in 2012-2016 its growth rate was 16.6% (R 2 = 0.879). A few regions were assigned to rank 5 (29.4-47.8 cases per 1,000 population), including Talovsky with 47.8 cases per 1,000 population (the growth rate of 4.7%), Kamensky with 39.7 cases per 1,000 population (the growth rate of 6.8%), Repievsky with 32.6 cases per 1,000 population (the growth rate of 33.8%), Vorobievsky with 30.31 cases per 1,000 population (the growth rate of 100.1%), and Nizhnedevitsky with 29.5 cases per 1,000 population (the growth rate of 12.9%). The lowest incidence (rank 1) was observed in Verkhnekhavsky, Kashirsky, Liskinsky, and Paninsky districts (4.1-11.0 cases per 1,000 population), but the growth rate in these districts was the highest (60.02-203.21%).

DISCUSSION
The selective analysis of data on the consumption of staple food products in Voronezh region collected in 1995-1999 and 2012-2016 demonstrates considerable changes in the local diet: increasing intake (per 1 person) of fish and seafood, fresh fruits, meat, vegetables, melons and gourds, eggs, vegetable oil, milk and dairy products. However, consumption of sugar, breads and potatoes is well above the norm (1.42-2.04-fold), meaning that the diet is still dominated by carbohydrates.
A similar study was carried out in the northern regions of Russia demonstrating that their population follows an imbalanced diet poor in meat, fish, seafood, milk and dairy products, unsaturated fat and rich in saturated fat and breads [5]. The populations of the North of Russia and Voronezh region have been sharing the same trend for many years consuming too much breads [12].
Over the two 5-year periods studied in this work the population of Voronezh region has been showing a 4.5-fold increase in obesity incidence, a 1.8-3-fold increase in the incidence of anemia and endocrine disorders and a 1.2-fold increase in the incidence of gastrointestinal diseases in the backdrop of imbalanced diet. These troubling trends have been highlighted in the works of some authors who studied nutrition and nutrient-related diseases and are typical for students who do not follow a balanced diet and do not have their meals regularly [13].
The study of the factors affecting the adaptation reserve of teenagers residing in the High North and the central part of Russia revealed changes in their immune status and blood chemistry caused by imbalanced diet; adaptive stress response was more pronounced in the teenagers of Russia's High North [14].
The growing incidence of nutrient-related diseases prompts the development of prevention measures and innovative approaches to food quality monitoring in the Russian Federation [15].
The incidence ranking for the districts in Voronezh region and identification of areas at risk are just the first step towards finding a solution to a problem of providing the population with safe quality food. We believe that priority in the prevention of nutrient-related diseases should be given to areas at risk. The diet offered to organized groups should include (if appropriate) products with a strong positive effect on health, as well as those boosting natural immunity [16]. Certain legal and technical aspects of specialized food production should also be improved [17]. So far, a few successful projects have been implemented in Voronezh region aimed at preventing iodine and fluorine deficiencies [12], reducing the level of food contamination based on the investigation of the associations between food quality and free radical oxidation [18]. At the same time, the problem of proper nutrition is complex and necessitates further elucidation of many of its aspects.

CONCLUSIONS
This study shows that the diet of the Voronezh region population is characterized by excess consumption of carbohydrates (breads and potatoes) and the lack of foods with high biological value (milk and dairy products, fresh fruits and vegetables). The incidence of nutrient-related diseases, such as endocrine disorders, obesity, and gastrointestinal diseases, is growing in the backdrop of imbalanced nutrition.
Our findings allowed us to identify the areas at risk of nutrient-related diseases and can be used to optimize the composition and quality of population diets.