Extending life: progress and achievements in 2017 of the WHO European Office for the Prevention and Control of Noncommunicable Diseases

iExtending life Progress and achievements in 2017 of the WHO European Office for the Prevention and Control of Noncommunicable Diseases ii All activities described here were funded completely or partially by a grant of the Russian Government in the context of the WHO European Office for the Prevention and Control of Noncommunicable Diseases. iii Extending life Progress and achievements of the WHO European Office for the Prevention and Control of Noncommunicable Diseases 2017 iv Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe UN City, Marmorvej 51 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office website (http://www.euro.who.int/pubrequest). © World Health Organization 2017 All rights reserved. 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IV: United Nations Information Centre in Moscow p. 1: WHO/ Yuriy Kochkin p. 2: WHO/ Yuriy Kochkin p. 4: WHO/ Tatiana Vorovchenko p. 5: WHO/ Yuriy Kochkin p. 7: WHO/ Malin Bring p. 9: WHO/ Rustam Toktokhunov p. 10: WHO/ Enrique Loyola p. 11: Public Health and Reforms Center of the Ministry of Health of Azerbaijan/ Ayten Mammadova p. 12: WHO/ Olga Manukhina p. 13-14: WHO/ Malin Bring p. 15a: WHO/ Serdar Seyidov p. 15b: WHO/ Serdar Seyidov p. 16: WHO/ Tatiana Vorovchenko p. 17: WHO / David Barrett p. 18a: WHO/ Faith Kilford Vorting p. 18b: WHO/ Tatiana Vorovchenko p. 19: WHO/ Rustam Toktokhunov p. 22: WHO/ Tina Kiaer p. 23: WHO/ Tatiana Vorovchenko p. 24: WHO/ Malin Bring p. 25: WHO/ Malin Bring p. 28: WHO/ Malin Bring p. 30: WHO p. 31: WHO/ Tatiana Vorovchenko p. 32: WHO/ Malin Bring United Nations House in Moscow, Russian Federation Document number: WHO/EURO:2017-3288-43047-60244 vContents Scope of work on NCDs 1 Progress in reducing premature deaths from NCDs 2 Saving lives, fighting NCDs in Europe: the contribution of Russian experts 3 WHO highlights NCDs at the 19th World Festival of Youth and Students in Sochi 4 International policy frameworks and commitments 5 Policy 6 Cooperation on health in the Commonwealth of Independent States 6 The NCD business case 6 Capacity-building workshops on NCD policy 7 Addressing NCD risk factors through the law 7 A course on tackling NCDs across the Russian Federation 8 Surveillance 10 Information systems in countries 10 NCD Country Capacity Survey 2017 11 STEPS 12 Establishing cancer registries 12 Prevention 13 Promotion of health at major sports events 14 Russia 2018: promoting health, tobacco-free environments and physical activity 14 Ashgabat 2017: promoting sports, physical activity and healthy diets in Turkmenistan 15 Healthy nutrition and diet 15 The WHO European Childhood Obesity Surveillance Initiative (COSI) 16 Obesity is on the rise, particularly among adolescents 16 Protecting children from the “hard sell” 18 Salt reduction 20 FEEDCities 20 Physical activity 20 Tobacco 22 Factsheets on strong tobacco-control policies 22 The Tobacco Control Playbook: a living document 23 Media and tobacco control in Tajikistan 23 Natural experiments 24 Alcohol 26 What’s in my drink? 26 Toolkit for alcohol screening and brief interventions 26 Management 27 Cancer 28 Package of essential NCD interventions for primary health care in low-resource settings (PEN) 29 Review of heart attack and stroke services 29 Scientific expertise and collaboration 31 Conclusion 32 References 33 1The NCD Office’s work is structured around four key areas: policy, surveillance, prevention and management. These map neatly onto the four time-bound commitments for prevention and control of NCDs of the 2014 United Nations General Assembly Outcome Document on NCDs (A/RES/68/271): adopting a national plan, setting national targets, reducing risks and strengthening health services for NCDs. The areas of prevention and surveillance are led by the NCD Office, while policy and management are led by the technical programmes of the Division of Noncommunicable Diseases and Promoting Health through the Life-course at the WHO Regional Office for Europe. Together these teams coordinate the European Region’s delivery of global and regional mandates on the Sustainable Development Goals (SDGs), the NCD Global Monitoring Framework and Health 2020 targets.1 An important part of the NCD Office’s work is education and training. This includes raising national capacity, enhancing leadership, promoting intersectoral action and enabling countries to adopt good practices and use international materials in Russian. Countries have a challenging task. Tackling NCDs involves working across sectors to address the risk factors associated with these diseases – cardiovascular disease, cancer, diabetes and chronic respiratory disease – and improving health system responses to people who contract them. It involves both implementing policies which enable and support healthy behaviours to prevent NCDs and building information systems to provide the baseline data and inform progress. The WHO European Office for the Prevention and Control of Non- communicable Diseases (NCD Office) in Moscow, Russian Federation, is an integral part of the WHO Regional Office for Europe and its Division of Noncommunicable Diseases and Promoting Health through the Life- course. This brochure highlights the full scope of the work of the NCD Office, which aims to strengthen health systems to facilitate noncommunicable disease (NCD) prevention and control. Funded by the Government of the Russian Federation, the NCD Office is playing an increasingly important role in supporting Member States as they make significant progress in addressing NCDs. Scope of work on NCDs “Today cardiovascular diseases, cancer, chronic respiratory diseases and diabetes kill three out of five people worldwide. The agenda dictates the need for an international discussion and exchange of experience on a number of critical areas in the fight against NCDs.” Professor Veronika Skvortsova, Minister of Health of the Russian Federation 2NCDs are the leading cause of death, disease and disability in the WHO European Region, accounting for an estimated two thirds of deaths among people aged 30–69 years. Over the past decade, however, there has been a marked decline in the prevalence of hypertension and in the number of people dying prematurely from NCDs. This gives rise to a hope that the European Region will reach the bold SDG target 3.4 – to reduce premature deaths from NCDs by 33% – before the target date of 2030, and even exceed it. National NCD experts from across the European Region raise their sights in Moscow In June 2017 the NCD Office convened over 150 experts from more than 30 countries across the Region to the WHO European Meeting of National NCD Directors and Programme Managers, to discuss whether the Region could raise its SDG target 3.4 from 33% to 45% by addressing the main NCD risk factors. The meeting was held in Moscow, Russian Federation, and the Russian Minister of Health and the representative of the State Duma reiterated the commitment of the host country to combating NCDs. This meeting was a significant tipping point in a general acceleration of global activity on NCDs. Discussions from the meeting contributed to the 2017 annual report developed by the NCD Office, Monitoring noncommunicable disease commitments in Europe,2 which was launched in October 2017 by Dr Zsuzsanna Jakab, WHO Regional Director for Europe, at the WHO Global Conference on NCDs in Montevideo, Uruguay. Both discussions and the report contributed to the Montevideo Roadmap 2018–20303 and will contribute to the third United Nations High-level Meeting on NCDs scheduled for 2018. As set out in the 2017 annual report, important progress has already been achieved in the WHO European Region in the fight against NCDs – notably in reducing premature mortality and hypertension. In her presentation in Montevideo, however, Dr Jakab emphasized the need for Member States to continue making timely interventions. Inequalities in premature deaths The European Region is leading other regions in reducing the risk of dying prematurely from NCDs, although inequalities remain within and between countries. Achieving a 45% reduction in premature mortality would necessitate closing the divide between NCD rates in eastern and western European countries. Major inequities also persist within countries in the Region, between populations from different socioeconomic groups and those living in different geographical areas. Recent analyses conducted by the NCD Office revealed strong gender inequity: most Progress in reducing premature deaths from NCDs The WHO European Meeting of National NCD Directors and Programme Managers, June 2017 3premature deaths occur among men and are caused by cardiovascular diseases. The majority of these premature deaths could be reduced through concerted action to accelerate NCD prevention and control. Gaps in surveillance of NCD risk factors The surveillance of NCD risk factors has improved significantly in the eastern part of the WHO European Region in the last two years, thanks to a generous grant from the Government of the Russian Federation and efforts by the NCD Office. It is nevertheless worrying that it is not currently possible definitively to assess indicators on physical activity, salt intake, drug therapy and counselling to prevent heart attacks and strokes, and on the availability of affordable basic technologies and essential medicines across the whole Region. Use of health examination surveys is also declining in the Region – even some of the wealthiest countries in the world are not currently conducting such surveys, leading to a lack of data for monitoring trends. Urgent action is needed to strengthen NCD surveillance systems if Member States are to meet the United Nations time-bound commitments and report accurately on the achievement of global targets in the future. Accelerating progress Promoting cardiovascular health is the key to reducing premature mortality. Current efforts by countries and nongovernmental organizations include raising awareness of the risk factors for stroke and coronary heart disease, such as tobacco, and encouraging better diets. Treatment of hypertension is a major contributor to reducing cardiovascular deaths, particularly if carried out with a unified and multidisciplinary approach. Tobacco use and alcohol consumption in the Region are declining too slowly, and prevalence of overweight and obesity is rising rapidly, so the global targets on NCDs in those areas are unlikely to be achieved. To address these challenges, WHO has identified a set of so-called “best buys” or cost-effective, high-impact interventions that influence all NCDs and their risk factors and thus lead to major public health improvements for both men and women. The best buys include implementing clinical interventions together with raising taxes on tobacco and alcohol, reducing salt consumption, eliminating trans fats in the food supply chain and promoting physical activity. Strengthening health systems’ response to NCDs is the key to achieving universal health coverage, but countries need to work beyond that and tackle the root causes – the social, economic, environmental and commercial determinants of health. This will lead to improved health outcomes and reduced inequalities, and will contribute to the sustainability of universal health coverage in the Region. The WHO European Meeting of National NCD Directors and Programme Managers weighed up the strong, albeit uneven, progress made so far and the opportunities presented by the implementation of best buys and tackling the root causes of NCDs – the social, economic, environmental “Although the WHO European Region as a whole has achieved substantial progress in reducing premature mortality from NCDs, there is no time for complacency. Governments need to act resolutely and implement the ‘best buys’ that have a rapid effect on mortality, such as controlling the price, availability and marketing of tobacco and alcohol.” Dr Zsuzsanna Jakab, WHO Regional Director for Europe Saving lives, fighting NCDs in Europe: the contribution of Russian experts The Russian Government has invested strongly in reducing mortality from NCDs: at the national level it has prioritized tackling them within domestic policies, and at the international level it funds the NCD Office in Moscow, providing outstanding support to the fight against NCDs regionally and globally. In recognition of this, and to discuss areas of future cooperation, in April 2017 the NCD Office and the Ministry of Health of the Russian Federation convened a meeting of the many Russian NCD scientists, health professionals and researchers from centres of excellence who, in collaboration with WHO, have shared their expertise internationally in the last few years. They were joined by representatives from various ministries – including health, finance and foreign affairs – the State Duma Healthcare Committee and the Federation Council Social Policy Committee. The meeting was opened by Dr Igor Kagramanyan, First Deputy Minister of Health. Over 40 Russian experts had been involved in over 20 WHO assessment visits and other activities across the Region, particularly in eastern European and central Asian countries, and one expert was invited to present at the Global NCD Conference in Montevideo, Uruguay, in October 2017. They shared their knowledge, skills and experience on strategic policy-making within public health, epidemiology, research and surveillance, NCD risk factors and prevention, as well as treatment of specific NCDs. The meeting was an example of the solid – and ongoing – partnership forged in the united effort to save lives and fight NCDs. 4and commercial determinants of health – as well as advances through innovation and new technologies such as electronic health records, big data and other forms of individual eHealth devices. Indications were that the WHO European Region can go beyond the SDG target 3.4 to reduce premature mortality from NCDs by 33% by 2030 and make possible a 45% reduction. WHO highlights NCDs at the 19th World Festival of Youth and Students in Sochi In October 2017 the Russian Federation hosted the 19th World Festival of Youth and Students in the Olympic village of Sochi, by the shores of the Black Sea. Over 25 000 young people and over 10 000 volunteers from over 100 countries participated in this large international youth event. The NCD Office ran a session on the threats posed by overweight and obesity not only to people’s health but also to the planet. Professor Veronika Skvortsova, Minister of Health of the Russian Federation, and Mr Sergey Yastrebov, Deputy Minister of Natural Resources and Environment of the Russian Federation, opened discussions on environment and health. The speakers discussed the role young people can play in protecting their own health, population health and the health of the environment. Building young people’s awareness of the issues of sustainable development is an essential part of the work of United Nations agencies. “Young people have a tremendous role to play in transforming our societies for the future we want, by taking action and protecting population health and the planet. They can drive forward the SDGs.” Dr Joao Breda, Head of the WHO European Office for the Prevention and Control of Noncommunicable Diseases Opening of the Environment and health session at the 19th World Festival of Youth and Students in Sochi, Russian Federation 5International policy frameworks and commitments Tackling NCDs is driven by the strategic objectives of reducing the burden of disease, improving equity and increasing participatory governance for health, as defined by Health 2020. It is also guided by the Global Action Plan on the Prevention and Control of NCDs 2013–20204 and the relevant WHO European strategies and action plans for NCD risk factors, prevention and control. The NCD Office is working to meet global goals and commitments to reduce NCDs, including a 25% reduction in premature deaths from the four major NCDs (cardiovascular diseases, cancer, diabetes and chronic respiratory diseases) by 2025 and a reduction of one third by 2030, as part of the SDGs. This work is informed by the following: • the Moscow Declaration, adopted in 2011 at the First Global Ministerial Conference on Healthy Lifestyles and NCD Control;5 • the Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases in 2011 (A/RES/66/2), progress against which will be reported at the Third United Nations High-level Meeting on Prevention and Control of NCDs in 2018; • WHO’s Global Action Plan for the Prevention and Control of NCDs 2013–2020; • WHO’s NCD Global Monitoring Framework; • the SDGs; • Health 2020 and its relevant targets on NCDs; • WHO’s Action plan for the prevention and control of NCDs in the WHO European Region 2016–2025;6 • the Montevideo Roadmap 2018–2030 on NCDs as a sustainable development priority; and • strategies and action plans such as the European Food and Nutrition Action Plan 2015–2020, Physical activity strategy for the WHO European Region 2016–2025, European action plan to reduce the harmful use of alcohol 2012–2020 and WHO Framework Convention on Tobacco Control.7 Professor Veronika Skvortsova, Minister of Health of the Russian Federation, addresses participants at the WHO European Meeting of National NCD Directors and Programme Managers, June 2017. 6Policy The WHO Regional Office for Europe supports countries as they work towards fulfilling their policy commitments. This can include advising on and assisting with establishing national targets, drawing up national intersectoral action plans or regulatory measures to comply with global or regional mandates on tobacco, alcohol, nutrition and physical activity; ensuring their implementation; assessing health systems and monitoring of progress. Implementation is facilitated by sharing current good practice and offering expertise from across the Region, contributing to training and consultation workshops, providing courses and other forms of capacity-building, evaluating action and progress under national plans and producing documentation. If national action plans are to work and be sustainable, they need to go beyond the health care sector to transport, nutrition, business, education, environment, housing and the law. Their strength is that they are based on evidence and include many stakeholders and professionals as well as decision-makers. During 2017 nine countries – Armenia, Georgia, Kyrgyzstan, the Republic of Moldova, the Russian Federation, Serbia, Tajikistan, Turkey and Uzbekistan – received support on developing or reviewing NCD action plans, one at the subnational level. A further two countries – Azerbaijan and Belarus – adopted plans during 2015–2016 and will be supported in implementation. Cooperation on health in the Commonwealth of Independent States NCD experts participate in international policy events and provide support to countries through their subregional networks, shaping international health governance across the European Region and beyond. In April 2017 the Council for Health Cooperation of the Commonwealth of Independent States (CIS) met in Bishkek, Kyrgyzstan, along with representatives from countries across the CIS, international agencies and WHO. They discussed the action plan for implementing the strategy “Health of the population of the Member States of the CIS”, promoting joint health programmes, information sharing, setting up a special body aimed at integrating efforts to protect the health of citizens in the CIS and working more closely with United Nations agencies. The NCD Office headed a discussion on innovations in the fight against NCDs. Professor Veronika Skvortsova, Minister of Health of the Russian Federation, was elected the next Chair of the Council, a position lasting for one year. The next meeting of the Council will take place in the Russian Federation in 2018. The NCD business case NCDs cost society dear. Making the NCD business case means examining the return that can be made from investing in NCD prevention and control. This is done by assessing the economic impact of NCDs, highlighting the importance of health in a prosperous economy and looking at the financial gains to society that accrue from investing in interventions to reduce NCDs. The cost of NCD treatment, shorter working lives and people dependent on others for support and survival all contribute to a massive bill for taxpayers. In 2011 the Political Declaration of the United Nations High-level Meeting on the Prevention and Control of NCDs called on international financial institutions, development banks, WHO and all other parts of the United Nations system and other key international organizations to work together in a coordinated manner to support national efforts to prevent and control NCDs and to mitigate their impacts. The United Nations Interagency Task Force on the Prevention and Control of NCDs (UNIATF) has built on this. Efforts are being made worldwide to overcome the inertia that sometimes inhibits intersectoral action and defines Action on NCDs in Kyrgyzstan A plan only works if it is implemented. In 2013 Kyrgyzstan adopted its NCD programme and action plan on NCDs for 2013–2020. Its aims are to reduce morbidity, premature mortality and disability from NCDs; the prevalence of NCD risk factors; and the social and economic burden of NCDs. In 2016 WHO was asked to conduct a mid-term review on the action plan’s implementation, to monitor progress made towards targets and identify the challenges and opportunities presented. Such reviews help to identify priorities when resources are limited. The work was co-funded through a voluntary donation from the Government of the Russian Federation and received technical leadership from the NCD programme of the WHO Regional Office for Europe. The Progress report on the implementation of Kyrgyzstan’s programme and action plan on prevention and control of noncommunicable diseases, 2013–2020, found that the SDG target on NCD mortality was on track, but stronger measures were needed to meet the targets related to alcohol, tobacco, diet and overweight and obesity. Key recommendations of the report included accelerating efforts to control NCD risk factors, increasing capacity in monitoring and evaluation, improving efficiency in allocating responsibilities and strengthening coordination and accountability so that more could be done. The review also recommended the creation of an NCD strategic unit within the Ministry of Health of Kyrgyzstan. 7the problem as one of personal choice rather than one where society as a whole, and governments in particular, have a strong role to play. Trade and competitiveness, labour and productivity, finance and revenue are all connected with government, the health sector and its strategies; together they can make a major difference to reducing NCDs and thus improve the economy. United Nations multiagency teams have been developing the NCD business case through assessment visits in pilot countries at the request of ministries of health. The results will contribute to national development of new initiatives, programmes and interventions. The process undertaken was reviewed as part of a global workshop led by UNIATF in January 2017, alongside similar initiatives in a small sample of other countries. The work was led on a technical level by the NCD programme of the WHO Regional Office for Europe and funded the Government of the Russian Federation. The business case was completed in Kyrgyzstan in 2017 and similar cases are under way in Belarus and Turkey. Further assessments will now be funded by the Government of the Russian Federation through a grant to the United Nations Development Programme and UNIATF, and will be expanded to cover three more countries in the WHO European Region, as well as others globally. Capacity-building workshops on NCD policy Addressing NCD risk factors through the law Trade measures, taxes and subsidies, appropriate packaging and labelling Raised blood pressure increases the risk of heart attack, stroke and kidney failure. Measuring and controlling blood pressure is an essential part of NCD prevention and control. 8standards and marketing restrictions all play an important role in the prevention and control of NCDs, and they all involve the law. In many countries, however, capacity in public health to develop and implement such laws and regulations may be limited. In 2016 a successful and intensive intercountry legal training course was held by the NCD Office on regulatory options. It was held in partnership with the I.M. Sechenov First Moscow State Medical University, Russian Federation, the Law and NCD Unit at the University of Liverpool, United Kingdom, and the McCabe Centre for Law and Cancer in Melbourne, Australia. Subsequently, a 2017 report entitled Key considerations for the use of law to prevent noncommunicable diseases in the WHO European Region9 summarized the lectures and discussions from the course. Many laws for NCD control and prevention have already been implemented in the Region – notably in the area of tobacco control – and Member States are moving towards the use of law to prevent NCDs in other areas as well, such as alcohol and food. Nevertheless, countries still face challenges when it comes to designing and framing the objectives of laws and avoiding or handling obstacles thrown in their path by commercial lobbies: this report will act as a primer on how risk factors can be addressed through the law. The course and the publication of this report would not have been possible without the financial support of the Government of the Russian Federation. A course on tackling NCDs across the Russian Federation In May 2017 the NCD Office supported a WHO training course on prevention and control of NCDs for decision-makers in the seven regions of the Russian Federation, in which 22 policy-makers from different sectors participated. The course aimed to increase capacity to develop and implement multisectoral plans for the prevention and control of NCDs, taking into account international recommendations and approaches, covering key topics such as the burden of NCDs and their risk factors, prevention and control programmes, multisectoral approaches, financial aspects of interventions and cooperation. Trainers delivered the content in an interactive way through moderated and round-table discussions and group-work sessions, resulting in draft regional NCD plans that could be integrated within local government programmes. The course received a warm welcome. The Government of Volgograd Oblast, recognizing the importance of urgent action to address NCDs, invited the WHO Collaborating Centre for Training and Education of Health Policy-makers on Prevention and Control of NCDs at the I.M. Sechenov First Moscow State Medical University to organize the course for a multidisciplinary team of policy-makers from the regional government. The NCD business case in Kyrgyzstan Almost 4% of Kyrgyzstan’s gross domestic product is lost due to NCDs. Prevention and control of noncommunicable diseases in Kyrgyzstan: the case for investment8 is a new report from WHO and the Kyrgyz Government, in collaboration with UNIATF and the United Nations Development Programme. It was launched at a multistakeholder forum with partner agencies in September 2017 in Bishkek, Kyrgyzstan, following an assessment visit and a workshop in Moscow, Russian Federation, in June 2016 to develop the methodology for the business case. The report shows that implementing measures to prevent NCDs would not only bring health gains for the population – half of whom currently die from cardiovascular diseases – but also have a return on investment of up to 12 times the cost of the intervention. Actions to prevent NCDs in Kyrgyzstan are relatively inexpensive and cost-effective. The analysis of intervention costs reviewed interventions in the areas of tobacco use, physical inactivity and unhealthy diet, as well as a package of clinical interventions for cardiovascular diseases and diabetes. The most cost-effective is a package of salt-reduction interventions. Reducing tobacco consumption – for example, through increased taxation – and increasing physical activity in the population would also be very economical. The costs of treating NCDs are soaring everywhere. The Government of Kyrgyzstan is estimated to have spent US$ 54 million on treatment for the four major NCDs in 2015, but this is just the start: it is estimated that hidden additional costs from lost productivity cost the country approximately US$ 213 million. The business cost is strong, therefore: investing to reduce NCDs and increase health is by far the wisest decision, for people’s health and for the national economy. The analysis was funded by a voluntary grant from the Government of the Russian Federation and presented at the Global NCD Conference in Montevideo, Uruguay. Mr Eroshenko, Deputy Minister of Health of Rostov Oblast: “We often attend different refresher courses and we were aware that we would deal with prevention. But within the framework of this course, we first heard of a global and international position and the view on this topic. The training course is interesting because it’s not just about lectures but also includes lively communication and practical work.” 9Affordable healthy food options, such as fruit and vegetables, are important in preventing NCDs. 10 in WHO’s NCD Global Monitoring Framework, Health 2020 and the SDGs. The work of the WHO Regional Office for Europe, including the NCD Office, reflects and addresses policy-makers’ key concerns about improving the quality of their routine data – including morbidity, disease registries, health-care management systems and policy statistics. The information is necessary to determine NCD morbidity and premature mortality risk trends and patterns; changes in NCD social health inequalities; the effectiveness of interventions on decreased prevalence and survival; the effects of quality of care on early diagnosis, treatment and rehabilitation; and the efficiency of screening, among other information for policy needs. The NCD Office’s work also increases the availability of new NCD data through ad hoc surveys, whether those on single risk factors such as the Childhood Surveillance Countries can more effectively tackle diseases if they have information on the current situation and trends. The NCD surveillance hub in the WHO European Region is based in and coordinated from the NCD Office. It helps countries to develop surveillance and monitoring systems that generate high-quality and comparable data on the main determinants, risk factors and mortality and morbidity burden of NCDs. Getting the full picture of NCD progress facilitates advocacy, policy development and coordinated action, and helps to reinforce political commitment. Monitoring and surveillance also provide internationally comparable assessments of the trends in NCDs over time. The NCD Office works towards harmonizing indicators across the European Region, as this will help countries to achieve the targets and outcome indicators proposed Obesity Surveillance Initiative, Global Adult Tobacco Survey and Global Youth Tobacco Survey or school-based surveys on multiple risk factors such as the Health Behaviour of School-aged Children and the increasingly valuable household-based WHO STEPwise approach to surveillance (STEPS) survey. Information systems in countries Online information is an area of constant innovation in surveillance. In the fight against NCDs, collecting data through consistent and comparable indicators from different sectors, combined with capacity- building to create an integrated platform, can make all the difference to evidence- informed policy-making. Policy-makers, national NCD programme directors and managers and their teams can be equipped with the relevant information, guidelines, standards and dynamic analytical and visualization tools to support effective WHO and national experts at an assessment visit in Turkmenistan, exploring the use of innovative data sources to establish an indicators and information platform to monitor progress on NCDs 11 policy-making, including monitoring and evaluation of NCDs. In 2015 the WHO Regional Office for Europe and NCD Office began work on developing an online portal of integrated NCD information: a single entry-point that draws together the information on NCDs from all Member States in the Region, covering health impacts, risk factors, health systems capacity and response, and policies. One of the outcomes of this ongoing work from 2017 was a set of NCD country profiles that combine information on selected indicators from WHO’s NCD Global Monitoring Framework and the WHO NCD Country Capacity Survey. These integrate several datasets in one visualization tool, making this rich information available in a single location and a user-friendly style, enabling easier use, analysis and interpretation. NCD Country Capacity Survey 2017 The global WHO NCD Country Capacity Survey is a web-based survey that aims to gauge the capacity of countries to respond to NCDs, including infrastructure and organizations, policy and action plans, guidelines to orient the work in clinical settings, health care resources and management, and monitoring and surveillance. Its objective is to guide WHO and Member States when planning future action to address NCDs. The survey provides the basis for an ongoing assessment of capacity and response within and between countries. It is also used for monitoring the United Nations time- bound commitment targets and indicators that will be discussed in 2018 at the Third High-level Meeting on Prevention and Control of NCDs. In 2017, for the first time, all 53 Member States in the WHO European Region responded to the survey. To improve the accuracy of the survey results, the NCD Office implemented an innovative strategy for their validation: all relevant programme managers, technical officers and heads of country offices were invited to provide STEPS in Azerbaijan and Belarus Azerbaijan is preparing for a second nationwide survey to assess the prevalence of NCD risk factors – tobacco, alcohol, lack of physical inactivity and dietary habits. The STEPS survey will take place throughout the country and include 2881 households, covering most districts. In preparation for this initiative, supervisors and data collectors attended an intensive five-day training course in Baku, Azerbaijan. This survey, following one held in 2011, will provide the opportunity to compare results and determine any changes in the prevalence of behavioural and biological risk factors of NCDs and in the effects of policies associated with them. The training course was conducted by experts from WHO headquarters and the NCD Office, financed through a voluntary contribution from the Government of the Russian Federation. Belarus conducted a national STEPS survey on the prevalence of major NCD risk factors among the country’s population aged 18–69 years for the first time in 2016. As elsewhere, NCDs remain the main cause of morbidity, disability and premature mortality in Belarus. The survey found that 40.5% of the male population have three or more risk factors. Further, 26.9% of adults are daily smokers; 52.8% have consumed alcohol in the last month, of whom 20% binge drink; 74% do not eat the recommended five servings of fruit and vegetables per day; and consumption of salt is twice the WHO-recommended limit. The survey results published in 2017 provide an objective view of the prevalence of NCD risk factors among the adult population of the country and will determine approaches to NCD prevention in Belarus in the coming years. Participants in STEPS training in Azerbaijan practising the use of glucometers to measure blood sugar levels 12 their input and additional information that might not have been captured by the survey questions. This significantly enhanced the validation process and improved the completeness of the responses gathered. The results of the 2017 WHO NCD Country Capacity Survey contributed to the NCD Office’s annual report, Monitoring noncommunicable disease commitments in Europe. STEPS The third indicator of the United Nations time-bound commitments requires each country to have a STEPS survey or comprehensive health examination survey every five years. The NCD Office has supported 13 countries to make progress on this indicator – including 12 countries in eastern Europe and central Asia – and to develop integrated information on NCD risk factors. The WHO STEPS survey is an internationally comparable, standardized and integrated surveillance tool through which countries can collect, analyse and disseminate NCD core information. It involves conducting detailed questionnaires of members of households, including taking their physical measurements and biochemical measurements from blood and urine. The standardized questions and protocols of the survey enable all countries to monitor national trends and develop integrated information on NCD risk factors. The survey results also enable comparisons across countries that help to identify good practices and inform the development of targeted policies and programmes. Its broad scope will help improve NCD risk factor prevention, health care management, monitoring and surveillance, since it provides data for 12 of the 25 outcome indicators of WHO’s NCD Global Monitoring Framework. The NCD Office has provided technical, financial and material resources to support the implementation of 11 STEPS surveys in eastern European and central Asian countries. Armenia, Azerbaijan, Belarus, Georgia, Kyrgyzstan, the Republic of Moldova, Tajikistan, Turkey, Turkmenistan and Uzbekistan conducted nationally representative STEPS surveys in 2011–2017, and Kazakhstan implemented the survey in two regions of the country. In addition, Ukraine is planning to undertake the STEPS survey for the first time, while Kyrgyzstan, the Republic of Moldova, Turkmenistan and Uzbekistan will conduct a second round of the survey in 2017–2018. Overall, by the end of 2018 NCD surveillance coverage in the European Region with the STEPS survey will have reached nearly 200 million people, or around 25% of the entire population. With enrolment of the Russian Federation, the NCD Office saw an unprecedented increase in the number of countries conducting the STEPS survey.. Establishing cancer registries Countries are interested in developing expertise in areas such as cancer registration methods. In collaboration with the International Agency for Research on Cancer (IARC), WHO has achieved significant progress in establishing and maintaining national high-quality cancer registries that can provide internationally comparable data. Population-based cancer registries are needed to quantify the burden of cancer and assess national prevention and control programmes. Well trained cancer registry staff play a crucial role in ensuring that data are of high quality and in providing accurate data analysis, interpretation and dissemination. Capacity-building courses to develop and improve capacity for cancer registration in countries in the WHO European Region are developed under the technical leadership of the NCD programme of the WHO Regional Office for Europe and funded by a voluntary donation from the Government of the Russian Federation. Some courses are held at the country level, such as that held in the In presenting the results Dr Valery Malashko, Minister of Health of Belarus, commented: “For the first time ever, we managed to get a comprehensive overview of the main risk factors of NCDs at the national level. Results of the STEPS survey will be actively used to monitor the state programme ‘People’s Health and Demographic Security of the Republic of Belarus 2016–2020.” Participants in the training course on cancer registries held in Moscow, Russian Federation 13 Russian Federation in October 2017 with more than 60 participants, who included analysts, epidemiologists and medical statisticians working in cancer registration, as well as other cancer registry professionals from 29 Russian regions and national institutions. Within- country support was also provided to six eastern European and central Asian countries: Azerbaijan, Belarus, Kazakhstan, Kyrgyzstan, the Republic of Moldova and Tajikistan. One result of this initiative was that Kyrgyzstan established a cancer registration team for the first time. Other courses bring different countries together, such as the international course on cancer registries held in December 2016 in Bishkek, Kyrgyzstan, whose participants included 26 analysts, epidemiologists and medical statisticians from nine countries: Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, the Republic of Moldova, Tajikistan and Uzbekistan. They particularly appreciated the opportunity to present their registries and receive comments from the group. To ensure full access to an expert NCD tool, a grant from the Russian Federation funded the development of the first Russian version of a manual on establishing and maintaining a cancer registry with IARC. This 45-page manual is essential to the implementation and development of population-based cancer registration in Russian-speaking countries. Prevention Most major NCDs are avoidable. By tackling major risk factors – such as tobacco and alcohol use, unhealthy diets and physical inactivity – at least 80% of all heart disease, stroke and type 2 diabetes and 40% of cancer could be prevented. Targeting risk factors is much less expensive than treating NCDs later : if they are reduced, the benefits are not only a healthier population that lives longer with less suffering, but also a country that is more prosperous and resilient socially and economically. The challenges for countries arise not only within the health system but also in work across sectors and in tackling areas 14 outside the traditional health system. This includes areas of the private sector which profit from tobacco, alcohol and food that is high in energy, fats, sugars or salt. WHO aims to reduce the exposure of individuals and populations to these NCD risk factors and to strengthen their ability to make healthier choices and follow lifestyle patterns that foster good health. Governments have to be the drivers that involve relevant stakeholders and promote the usefulness of documenting and disseminating best practice in the European Region, ensuring that assessments, national plans and capacity- building all recognize the need for an intersectoral approach for diet, smoking, alcohol and exercise –lifestyle choices strongly affected by big business and other stakeholders. The WHO NCD experts from the NCD Office and the Regional Office for Europe participate in technical visits to countries in the WHO European Region to provide advice and support on tackling the key NCD risk factors. Promotion of health at major sports events Global sports events such as the Olympic Games, World Cup and others promote healthy lifestyles among their participants and spectators, and provide a unique opportunity to leave a long-lasting public health legacy to the host country and beyond. Experts from the WHO Regional Office for Europe and the NCD Office provide technical support and build the capacity of organizers to ensure healthy environments during these competitions. Russia 2018: promoting health, tobacco- free environments and physical activity The World Cup showcases the world’s best football players and attracts millions to its matches; billions of people globally watch the matches on television. This creates an ideal platform to stimulate action to promote healthy behaviour and reduce NCDs. International football events have been tobacco-free since 2002, and following the 2017 Fédération Internationale de Football Association (FIFA) Confederations Cup in the Russian Federation, the country is now preparing for the 2018 FIFA World Cup, known as “Russia 2018”. Commercial businesses can also play a role in preventing NCDs. A supermarket in North Karelia, Finland, promotes seasonal fruit and vegetables each month with special displays, posters and cooking tips. 15 In April 2017 in Kazan, Russian Federation – one of the 11 host cities for the World Cup – host city administrators responsible for ensuring healthy and smoke-free environments joined with WHO, federal and regional ministries of health and sport, Russian experts and international speakers. The aim was to learn more about NCDs and the many ways in which large-scale events can be used to promote health through public health information and communication, including involving the local community in physical activity. The NCD Office continues to work with the local organizing committee of Russia 2018 on promoting a healthy lifestyle and sport and ensuring a tobacco-free environment during the 2018 World Cup. Ashgabat 2017: promoting sports, physical activity and healthy diets in Turkmenistan The 5th Asian Indoor and Martial Arts Games was held in September 2017 in Turkmenistan. In preparation, a conference took place in April 2017 involving national and international participants, WHO and other United Nations agencies to discuss the role of sports and high-profile sporting events in promoting healthy diets, physical activity and gender equality. The health benefits of physical activity include reduced risks of NCDs such as obesity, diabetes, cardiovascular disease and depression, but many people do little exercise. The evidence shows that socioeconomic determinants and gender norms tend to reduce access to physical activity, exposure to health promotion and accessibility of health services. Across the WHO European Region, girls do much less physical activity than boys throughout their lives. Involving girls and women in sports not only increases their fitness, empowerment and equality in health, it also improves maternal and child health outcomes. Turkmenistan now has policies to ensure that girls and women are physically active. The proposed national strategy on physical activity in Turkmenistan is expected to be adopted soon, and this is backed up by the national action plan for gender equality in Turkmenistan. Healthy nutrition and diet A balanced and varied diet composed of a wide range of nutritious and tasty foods adds years to life and life to years. In 2017 NCD Office experts conducted visits to Armenia, Bosnia and Herzegovina, Kazakhstan, the Russian Federation and Uzbekistan to support them in developing and implementing policies that enable their citizens to make healthier food choices and protect them from aggressive advertisement of unhealthy foods. The NCD Office also supports countries in conducting studies to assess the current composition of available foods and assessing salt intake. The WHO European Childhood Obesity Surveillance Initiative (COSI) Dr Bahtygul Karriyeva, WHO Representative in Turkmenistan, and Dr Joao Breda, Head of the NCD Office, in Turkmenistan in preparation for the 5th Asian Indoor and Martial Arts Games Participants in the conference on promoting sports, physical activity and healthy diets in Turkmenistan 16 COSI is established in 39 Member States in the WHO European Region and involves over 300 000 children; the number of countries and children grows with each data collection round. It is unique and the largest initiative of its kind in the world. Participating countries measure trends in overweight and obesity among primary schoolchildren aged 6–9 years to understand the progress of the epidemic in this population group, gain intercountry comparisons within the European Region and inform action to reverse the trend. Together with technical staff based at the Regional Office working in the area of nutrition, obesity and physical activity, the NCD Office provides support for implementing and expanding COSI in the European Region. It collaborates with institutions in the Russian Federation with experience in nutrition, childhood obesity and evaluating children’s nutritional status, facilitating country access to survey tools by ensuring translation into Russian. With its support, 14 countries joined the Initiative for the first time, for the fourth data collection round in 2015–2016: Austria, Croatia, Denmark, Estonia, Kazakhstan, Montenegro, Poland, the Russian Federation, San Marino, Serbia, Slovakia, Tajikistan, Turkmenistan and Ukraine. In 2016–2017 the NCD Office supported pooled data analysis at the aggregated level involving all COSI countries and provided specific support to 11 countries with sampling and data analysis, including Albania, Hungary, Kazakhstan, Poland, the Republic of Moldova, Romania, the Russian Federation, Slovakia, Tajikistan, Turkmenistan and Ukraine. For many countries, this is the first time they have collected data on child growth for school-aged children. Obesity is on the rise, particularly among adolescents Obesity is preventable. Ending obesity, however, is very complex. The prevalence of childhood obesity in nearly every country around the globe is increasing at an unprecedented rate, and yet few countries have pushed this public health issue to the Excess calories from foods and drinks high in free sugars contribute to overweight and obesity. 17 top of the political agenda. As the challenge becomes ever more serious, 2017 has seen a surge in initiatives to tackle obesity among children and adolescents, in which the NCD Office has played a key role. To tackle the rise in adolescent obesity, the NCD Office supported development of a publication entitled Adolescent obesity and related behaviours.10 This study analysed the wide-ranging data collected by WHO’s collaborative cross-national study the Health Behaviour of School- aged Children (HBSC) survey. The data demonstrate the latest trends in obesity, eating behaviours, physical activity and sedentary behaviours of 11-, 13- and 15-year-old boys and girls, covering 44 countries in the European Region over The Russian Federation conducts its first COSI survey The Russian Federation joined COSI in 2016 and started its first COSI survey in 2017. The survey is led by the federal Endocrinology Research Centre; it will provide a clear understanding of the dynamics of the obesity epidemic and assess the interventions that have been taken to reduce the prevalence of childhood obesity in the country. It will also facilitate comparisons of trends with other countries of the WHO European Region, since the instrument and protocol are standardized for all user countries. The 60 paediatricians, paediatric endocrinologists and nutritionists in the national COSI team were trained by WHO experts. NCD Office experts also supported the national team in forming a random sample of 72 schools with primary classes in Moscow, where the study will be conducted. The study will involve 3000 7-year-old children from primary schools. As part of a COSI survey, children are measured to assess trends in overweight and obesity among primary schoolchildren around the Region. 18 the past 25 years and highlighting gender and socioeconomic inequalities. The number of adolescents with obesity has increased in more than half the countries in the Region; childhood obesity has become one of the major public health challenges for the 21st century. Despite sustained efforts to tackle childhood obesity, one in three adolescents is still estimated to be overweight or obese in the Region, with the highest rates found in southern European and Mediterranean countries. Furthermore, the epidemic is on the rise in eastern European countries, where rates have historically been lower. As parents know all too well, adolescents spend most of their time sitting down, and eat too many sugary products and too few vegetables; this has serious repercussions. Most young people will not outgrow obesity: about four in every five adolescents who become obese will continue to have weight problems as adults and will be at increased risk of developing ill health. Ambitious policy action is needed to break this harmful cycle from childhood into adolescence and beyond, reducing the appeal of foods high in fat, salt and sugar, and re-establishing physical activity as an integral part of daily living. The most marked increases in obesity have been observed in eastern European countries, and an estimated 27% of all adolescent obesity in Europe in 2014 was attributed to socioeconomic differences, up from 18% in 2002. However, an increase in screen-time-related sitting is common to all countries, now accounting for between 40% and 60% of overall sitting time: the current guideline of less than two hours per day of recreational screen time is met by only a minority of European adolescents. Public health action is needed to implement interventions on an international scale to reduce screen- time behaviours in young people. The report was launched in Moscow, Russian Federation, and Porto, Portugal, and received wide coverage in international media. At the launch, the HBSC principal investigator in the Russian Federation and scientific expert at the St Petersburg Scientific-Research Institute of Physical Culture focused on the key findings of the report for the Russian Federation. Between 2002 and 2014 the prevalence of obesity in the country increased fourfold among girls and threefold among boys, and in 2014, 2% of girls and 5.4% of boys were obese. Although the amount of time spent watching television decreased, time spent sitting in front of computer screens has increased considerably. Protecting children from the “hard sell” Children are subject to high-pressure advertising and marketing of high-salt, energy-dense, sugary snacks and food of little nutritional value, which evidence shows has a causal effect on their food preferences and dietary behaviours, thus influencing obesity outcomes. The WHO European Action Network on Reducing Marketing Pressure on Children is addressing this by sharing positive experiences, innovative practice and evidence on what is working best through regulatory or voluntary approaches to Dr Svetlana Axelrod, Coordinator of Integrated Country Support Programmes at the NCD Office and a new WHO Assistant Director-General on Noncommunicable Diseases and Mental Health received an award for achievements in international health policy from Mr Vladimir Putin, President of the Russian Federation. Children are subject to high-pressure digital advertising and marketing of unhealthy foods. 19 reduce this pressure. In May 2017 the Network met in Dublin, Ireland, and 16 countries were represented. There was growing concern about the inappropriate promotion of foods for babies, infants and young children, as well as digital marketing. A new publication was presented to the meeting: Monitoring food and beverage marketing to children via television and the Internet.11 A voluntary contribution from the Government of the Russian Federation enabled the WHO Regional Office for Europe to develop this research protocol, which is an invaluable tool to support Member States in assessing the extent and nature of the marketing to children of food and drinks that have a high content of saturated fats, salt or free sugars. In the Russian Federation the NCD Office has been working with the National Research Centre for Preventive Medicine to implement the study. Russian researchers analysed five television channels whose target audience is children and adolescents, as well as Internet websites of companies which are signatories to a self-regulatory European Union pledge to limit marketing to children: these include the most popular food brands in Europe and the United States of America. Plans are under way for the Research Centre to support similar work in other countries in 2018. A participant from the Kazakhstan Centre for Healthy Lifestyles participated in a training workshop in Moscow on how to use the protocol for research purposes. The protocol and accompanying coding forms allow each Member State to tailor research to its specific needs. This research will produce data on both the persuasive techniques employed and the forms, methods and amount of marketing to children. The protocol has been designed so that the resources required can be minimized and remain relatively low if data are collected manually, avoiding costs associated with purchasing from commercial sources. It is expected that the data obtained will provide evidence of the Salt intake in Uzbekistan is three times too high The average salt intake by adults in Uzbekistan is 14.9 g per day, which is almost three times higher than the WHO recommendation of less than 5 g per day. In a significant study conducted with WHO experts, a team of doctors from Uzbekistan collected data in 2015 in five regions of the country, assessing salt intake by measuring sodium excretion in individuals’ urine during a single 24-hour period, stratified by age group, and considering WHO recommendations and technical advice. This allowed them to compare data with a wide range of similar studies. The launch of a national report and a policy dialogue in December 2016 in Tashkent, Uzbekistan, were made possible by funding from the Government of the Russian Federation and the WHO Regional Office for Europe. It is hoped that the Ministry of Health of Uzbekistan will approve a series of follow-up activities on salt reduction, setting an initial target level of the average salt intake of 10.4 g per day by 2025, to be achieved through appropriate policies and targeted measures. Street food in many eastern European and central Asian countries was found to have excessive salt, fat and sugar. 20 need to improve legislation in the field of food marketing. Salt reduction People in the WHO European Region consume too much salt, and high salt consumption contributes to increased blood pressure. Halving salt intake to the recommended level of 5 g per day for adults would result in a 24% reduction in strokes and an 18% reduction in coronary heart disease. Salt is often hidden in food products, however, and many people are unaware of how much salt they are consuming. In May 2017, 15 countries were represented at a meeting of the WHO Action Network on Salt Reduction in the Population in the European Region in Dublin, Ireland. Participants shared best practices, harmonized monitoring data and discussed and other cardiovascular diseases. To investigate the nutritional value of urban food environments, which have been little studied, FEEDCities was devised: an innovative multicountry study for which the NCD Office has created a platform and designed its methodology alongside external experts from University of Porto, Portugal. The FEEDCities study involves analysing the trans-fatty acids and sodium content of food sold in markets – both homemade and industrially processed – using laboratory analyses of locally obtained food samples. The NCD Office has supported staff from the Regional Office for Europe, WHO country offices and the University of Porto in carrying out fieldwork in six countries so far – Bosnia and Herzegovina, Kazakhstan, Kyrgyzstan, the Republic of Moldova, Tajikistan and Turkmenistan. The fieldwork teams worked with national experts, and analysis of food samples collected was funded by the NCD Office with technical support from the University of Porto in Portugal. Turkmenistan’s National Centre for Public Health and Nutrition, which has state-of-the-art facilities, received additional training in the analyses required for this project and will support further analyses in the Region. As suspected, food-composition studies revealed very high levels of trans-fatty acids and salt in common foods sold in markets and gave solid evidence for designing policy interventions aimed at eliminating trans fats in the food supply and reducing the salt content of common foods. Further surveys are ongoing or planned in Georgia and Uzbekistan. Physical activity Physically active people enjoy greater health, longevity and general well-being. Physical inactivity is estimated to be the primary cause of approximately 21–25% of breast and colon cancers, 27% of diabetes and 30% of ischaemic heart disease, which can result in stroke. In the WHO European Region, a million deaths (about 10% of the total) and 8.3 million disability-adjusted Upcoming publication on modelling sodium reduction in foods In collaboration with Australia’s George Institute for Global Health, WHO is developing models within eastern Europe and central Asia to demonstrate the feasibility of reducing the population’s salt intake to the WHO-recommended level of less than 5 g per day. These models may also inform future salt-reduction strategies in other countries by identifying the main contributors of salt in the diet, the foods with high sodium content and the changes in food supply and consumption required. A model for Kazakhstan was developed using available data from dietary intake surveys and urinary sodium excretion. It found that to reach the WHO- recommended target there needs to be both a reduction in the sodium content of foods and a change in consumer behaviour to use less discretionary salt and eat less salty foods. A 28% reduction in the sodium content of processed or packaged foods is required, in combination with a 40% reduction in the use of cooking salt, a 65% reduction in the consumption of mineral waters and a 30% reduction in consumption of salty meat and vegetable dishes. The next step as part of this NCD Office project is to develop, in collaboration with the George Institute for Global Health in Melbourne, Australia – a WHO Collaborating Centre, a “how-to” guide for countries to develop their own salt models. Experience of working on this topic underlines the continuing importance of countries collecting better data on dietary intake (to identify sources of sodium in the diet) and monitoring salt intake (to establish a baseline). innovative approaches to reach the WHO NCD Global Monitoring Framework target of reducing sodium intake by 30%. Supporting countries as they take measures to analyse salt consumption and advising on the best ways to reduce intake is a central part of the work of the NCD Office. FEEDCities Good nutrition and healthy diet play a vital role in reducing NCDs. Markets and street food stalls are an important part of the culture in many countries. They can provide a diverse range of nourishing fruits, vegetables, nuts and whole grains, but increasingly they also sell food that is high in calories, trans fats, sugar and salt. Strong evidence links trans-fatty acid intake to coronary heart disease, and excessive salt intake can significantly increase blood pressure, which is a major driver of stroke 21 Street food in Kazakhstan, Kyrgyzstan, the Republic of Moldova, Tajikistan and Turkmenistan Tajikistan was the first country to launch the data collection phase of FEEDCities, with a team of fieldworkers receiving training from WHO and project partners from the University of Porto, Portugal. They canvassed 10 street markets, interviewed 1073 vendors and collected 100 homemade and 40 industrially processed food samples. The homemade foods in this area included bread such as lavash and lepyoshka, savoury pastries such as piroshky and chebureki, samsi – baked meat pies, cooked in a tandoor – and soups. The second country to complete the study was Kyrgyzstan, where typical local traditional foods include meat or vegetable dumplings. Industrially processed foods are also commonly available in both countries, including cookies, cakes and potato chips. In Chisinau, Republic of Moldova, the third country in the project, commonly available ready-to-eat street food includes industrially processed chocolate, sweet baked goods and crackers, but also homemade foods: sweet pastries such as placinta and kebabs such as shwarma. As a result of these studies two WHO FEEDCities project reports were launched from Tajikistan and Kyrgyzstan. A third report from the Republic of Moldova is expected to be published before the end of 2017. Studies are ongoing in Kazakhstan and Turkmenistan. While bazaars and markets in Bishkek, capital of Kyrgyzstan, and Dushanbe, capital of Tajikistan, have historically been a rich and important source of fresh food, particularly fruit and vegetables, the population also buys ready-made and ready-to-eat street food there. The WHO reports found that the street food in both countries has high levels of trans-fatty acids and sodium, which are major risks to health. Sugary drinks are also widely on sale in the markets, contributing to excess energy intake and weight gain. Cardiovascular disease accounts for 49% of all deaths in Kyrgyzstan; in Tajikistan cardiovascular diseases, cancer, respiratory diseases and diabetes now account for more than 50% of all deaths. The reports recommend that urgent action be taken, possibly including regulation, to promote access to affordable, nutritious street food. Policy actions to move towards a healthier street food environment should be incorporated into existing programmes, such as national NCD programmes and national food security and nutrition programmes, to strengthen the promotion of healthy diets Eating too much salt causes high blood pressure, stroke and kidney disease. Eating trans fats increases the risk of coronary heart disease. An average-sized bowl of soup from a Tajik market contains 125% of the WHO-recommended maximum intake of A typical wafer from a Kyrgyz market contains 170% of the WHO-recommended maximum intake of The FACTS about central Asian street food Street food is a widely accessible and inexpensive source of food in central Asia. However, it can contain high levels of SALT and TRANS FATS, which increase the risk of cardiovascular disease. TRANS FATSSALT www.euro.who.int/nutrition 11/2017 WHO recommends eating less than 1 teaspoon of salt per day and limiting trans fats • Introduce laws that limit salt and trans fats in food production. • Eliminate the use of industrial trans fats in food production. • Inform consumers about the risk of eating food high in salt and trans fats. • Promote continued access to fruit and vegetables at street markets. What can be done to make street food healthier? 22 within 15 years and 46% within 40 years across the newly independent states with stronger policies such as an increase in tobacco taxes, enforcement of smoke-free laws and banning tobacco advertising. The factsheets will be a useful tool for policy- makers, public health professionals and other interested users in assessing which measures will have the strongest impact. life-years lost per year are attributed to physical inactivity, which also contributes to the energy imbalance that leads to weight gain. Physical inactivity therefore not only has substantial consequences for the individual and the population; it also carries direct health care costs and high indirect costs due to increased periods of sick leave, work disabilities and premature death. Improving physical activity is an investment in the future of adults, children and society. The NCD Office supports countries as they develop policies, structures and measures to make it easier for people to adopt healthy lifestyles and reduce their risk of contracting NCDs. In 2017 NCD Office experts provided support to countries to create enabling environments and promote active living and mobility, sustainable development and healthy communities. Tobacco Tobacco use is the single most preventable cause of death and disease in the European Region: WHO has estimated that it is currently responsible for 16% of all deaths in adults aged over 30 years in the Region, with many of these deaths occurring prematurely. Among WHO Regions, the European has the highest prevalence of tobacco smoking among adults (28%) and some of the highest prevalence of tobacco use by 15-year-old adolescents (12% for boys and 11% for girls). Factsheets on strong tobacco-control policies With funding support from the Government of the Russian Federation, the WHO Regional Office for Europe developed a series of fact sheets for the 11 newly independent states (Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, the Russian Federation, Tajikistan, Turkmenistan, Ukraine and Uzbekistan), each tailored individually to a country.13 These demonstrate the positive health impact of strong tobacco- control policies consistent with the WHO Framework Convention on Tobacco Control. They include projections made with an abridged version of the SimSmoke tobacco-control model, which shows that smoking prevalence can be reduced by at least 28.5% within five years, 39.1% New publication on urban design and planning to promote physical activity In November 2017 WHO launched a publication that looks at how design and planning in the urban built environment can promote physical activity.12 In many cities cars dominate, and open spaces are in short supply: there is little opportunity for children or adults to run around, play games, enjoy open-air exercise or keep fit. Yet these activities not only contribute to well-being but are vital to reducing the risk factors that lead to NCDs. The new publication is designed to lead to action. It considers what barriers currently exist, what types of physical activity can be promoted, who should be targeted and when, and how best to plan and implement appropriate measures, adjusting for social justice and equity. This includes consideration of design in the use of inner-city land, housing estates, transport and public spaces. Political agreement is important in making progress, and cities can take simple steps, even within their current planning policies, that will make a difference. A grant from the Government of the Russian Federation enabled this report to be translated into Russian. Journalists in Tajikistan increase their skills in reporting on tobacco at a WHO-led training course. 23 The Tobacco Control Playbook: a living document The Tobacco Control Playbook,14 developed in 2015 by the WHO Regional Office for Europe, is an accessible online tool that counters many of the myths about tobacco often presented as truths by the tobacco industry. It is proving to be very popular and is helping policy-makers counter aggressive tobacco-industry tactics. The industry and its allies have consistently opposed effective tobacco- control measures, and their strategies and efforts to subvert the policy process have become even more determined, focused, misleading, aggressive and sophisticated. Policy-makers need to be equipped with clear facts and well founded arguments to counter the myths generated by the tobacco industry. In 2017 further arguments were developed and added to the Playbook: its new look and layout was unveiled in Moscow, Russian Federation, at the June 2017 WHO European Meeting of National NCD Directors and Programme Managers. Subscribers can now receive newsletters with regular updates and new arguments; WHO/Europe encourages experts and other stakeholders in such efforts to provide feedback on the Playbook and contribute their own knowledge by sharing experiences, best practices and lessons learned. In the face of ruthless and cynical opposition from the tobacco industry it is necessary to do more than simply cite evidence-based research. For this reason, the Playbook also offers a well developed narrative that challenges the most common myths about tobacco control. The Playbook was developed under the technical leadership of the tobacco programme. The governments of the Russian Federation and Turkmenistan funded translation into Russian and communications support to ensure dissemination of the Playbook. Media and tobacco control in Tajikistan Journalists can play a unique and vital role in raising awareness about the dangers of smoking and in building public support for tobacco-control initiatives. Tajikistan hosted a two-day workshop in Dushanbe in March 2017, organized by the WHO Regional Office for Europe, that brought together nearly 30 members of the media, as well as representatives of government ministries, health organizations and the consumer protection association, to Russian Federation: a success story on tobacco control In 2009 the Russian Federation had one of the highest number of smokers in the world. Almost 44 million adults smoked, despite 90% of them agreeing that smoking causes serious illness. Strong action was needed, and in 2010 the Russian Government introduced the “National strategy on creation of a public policy to combat tobacco consumption for the period 2010–2015”. This was followed in 2013 by strong anti-tobacco legislation, reflecting the obligations in the WHO Framework Convention on Tobacco Control, which the Russian Federation had ratified in 2008. Increases in tobacco taxes are known to reduce tobacco consumption faster than any other single measure, and in the Russian Federation tobacco taxes have been raised over the last seven years by at least 30%. Cigarette prices rose by 150%, sales decreased by 27% and cigarette smuggling fell from nearly 7 billion cigarettes in 2009 to 1 billion in 2015. Tobacco control lowered the sales of tobacco by almost 30% and the number of smokers by 21% from 2009 to 2016. Tobacco taxation is crucial to achieving a one third reduction globally by 2030 of premature deaths from NCDs. Details can be found in a 2017 WHO report entitled Tobacco control: a comprehensive approach at country level in the Russian Federation,15 which is available in Russian and English. Slovenian tobacco- control law Every day 10 people in Slovenia die from illnesses related to smoking tobacco. In February 2017 the National Assembly of Slovenia unanimously adopted a new tobacco-control law. This includes measures such as plain packaging, a ban on smoking in private cars in the presence of minors, a display ban at the point of sale, an earmarking excise tax, licensing to sell tobacco products and a doubling of fines – for example, a fine of €50 000 for selling tobacco and related products without a licence. The new law also addresses the sale and advertising of electronic cigarettes. Slovenia is paving the way to a smoke-free society. 24 expand their skills in reporting on tobacco. Smoking prevalence in the country is relatively low (17% for men and 0.3% for women), but this makes the country a prime target for the tobacco industry in the coming years: women and young people are likely be the focus of marketing efforts. It will be critical for Tajikistan to implement strong anti-tobacco measures before the tobacco industry has a chance to make headway, and for journalists to have the facts at their fingertips. Tobacco control is a high priority in Tajikistan. Smoking currently contributes to premature death for half the 467 100 people who currently smoke. The workshop equipped journalists with national and international data and overviews of the WHO Framework Convention on Tobacco Control and the process undertaken by the Russian Federation to control tobacco. With hands-on exercises and simulations, they were also introduced to the Tobacco Control Playbook. This was the third workshop for journalists supported by the NCD Office, and was widely welcomed. Natural experiments In early 2017 WHO Regional Office for Europe invited a selection of countries in the Region to nominate research teams to take part in a natural experiment study project and attend a technical workshop in Copenhagen. This project’s innovative approach involves assessing whether a policy has an impact on a population by looking at the data in a natural environment. This involves conducting so-called “natural experiments”, such as monitoring the health effect of introducing a sugar tax in one city by comparing it to a neighbouring city with no sugar tax. During the workshop and through follow- up support exercises since, countries have identified existing national interventions in their countries for the prevention and control of NCDs, and have developed study protocols that will use natural experiment study techniques to evaluate these. Six countries (Austria, Hungary, Romania, the Russian Federation, Turkey and Ukraine) are currently involved in the project, running seven studies in total (testing alcohol control, trans-fats Alcohol is a major risk factor for noncommunicable diseases – WHO offers support for countries to put evidence-based policies into effect to limit consumption. 25 One of the best ways to prevent and control NCDs is making interventions an integral part of primary health care. 26 regulation and tobacco-control measures). In November 2017 preliminary findings from these studies were presented at the 10th European Public Health Conference in Stockholm, Sweden. From November 2017 to February 2018 the Regional Office and the external experts involved in the project will continue to support the country research teams to complete data collection, analysis and interpretation. Final studies will be completed by March 2018, and a selection or series of publications by June 2018. The aims of the project are to improve the culture of and increase the capacity for high-quality evaluations of public health interventions for NCD control; to use learning from this process to develop further capacity-building activities; and to improve the evidence base for the global NCD agenda and the case for investment in NCD control. This innovative approach has raised international attention and it was made possible by funding via a grant from the Government of the Russian Federation. Alcohol The WHO European Region has the highest levels of alcohol consumption and alcohol- related harm in the world, and – at 16.5% of the total population aged 15 years and over – the highest prevalence of binge drinking, which is particularly harmful to health. Young people are among those most affected by alcohol-related problems. Although many people do not fully realize the harm it does, use of alcohol is a major avoidable risk factor for neuropsychiatric disorders, cardiovascular disease, cirrhosis of the liver and cancer, as well as damage to the fetus. It is associated with several infectious diseases and contributes significantly to unintentional and intentional injuries. Alcohol also harms people other than the drinker, whether through violence, traffic accidents, domestic violence or simply using up government resources. Yet for many people professional help comes too late. It has been estimated that only one in 20 of those with hazardous or harmful alcohol use issues is actually identified and offered advice by a primary care provider. Nevertheless, relatively simple and inexpensive measures can bring rapid and considerable gains in population health and well-being, enhanced employment and productivity, increased health and social welfare savings, greater health and economic equality, and greater social cohesion and inclusion. A decisive public health response is possible and effective, and WHO offers support to countries to put in place those tried and tested policies on alcohol which can make a difference. What’s in my drink? One innovation being tried out in some European countries is the labelling of alcoholic drinks. In 2017 the WHO Regional Office for Europe published, in association with Eurocare, Alcohol labelling: a discussion document on policy options,16 which covers the legal framework, research findings and information on nutrition, design and effective messages. Studies in Europe have shown that consumers would welcome knowing the carbohydrate, calorie and fat content of their drinks and the different ingredients used in their production so they can make an informed choice, as they already can with non-alcoholic drinks. The publication will be available in Russian, thanks to the support of the Government of the Russian Federation. Toolkit for alcohol screening and brief interventions In an effort to assist countries in introducing or expanding alcohol screening and brief Alcohol taxation policies in Kyrgyzstan, 2017 Kyrgyzstan introduced strong alcohol taxation policies in 2012. A new report, soon to be available in Russian through NCD Office support, describes them and outlines their impact on revenue and alcohol-related harm from 2006 to 2016.19 The increasing cost of alcohol resulted in a decline in alcohol turnover and consumption and alcohol-related harm. While taxation policies in Kyrgyzstan appear to have had a positive impact, the report also recommends that tax increases should be accompanied by government efforts to control the production, sale and consumption of illicit alcohol. New report on alcohol in Croatia A new WHO report entitled Alcohol as a public health issue in Croatia17 analyses alcohol consumption, alcohol-related harm and existing policy measures in Croatia, and explores areas that would benefit from improvement. The author recommends development of a comprehensive alcohol strategy and a national action plan, which would help to combat the harms related to alcohol use, as would the establishment of some form of independent and high-level state body. Multisectoral action is a vital component for progress, and particular attention needs to be paid to young people to support them in building and maintaining a healthy lifestyle. The report was supported by funding from the Government of the Russian Federation through the NCD Office. 27 Armenia hosts round-table on prevention and control of NCDs In Armenia NCDs account for 92% of deaths, with cardiovascular disease the main killer (54%); 77% of premature mortality is related to NCDs. With the adoption of the “Strategic Programme for the Prevention and Control of NCDs for 2016– 2020” and the related action plan, the Government of Armenia is making significant efforts to address this leading cause of premature death and avoidable disability. In March 2017 WHO and the Ministry of Health of Armenia convened a round- table discussion on prevention and control of NCDs. The deputy minister of health said that reducing NCDs would have a direct and beneficial impact on the economic development of the country. Participants were advised that addressing an NCD risk factor as important as tobacco had to involve working closely with other government agencies, such as the ministries of economy, finance and education, and with civil society. International experts presented two guiding documents to accelerate implementation of high-priority actions: a report on health system challenges and opportunities to improve NCD outcomes in Armenia and the preliminary findings of the WHO STEPS survey, implemented in Armenia in 2016. Workshops were facilitated by international experts. The meeting was supported by funding from the Government of the Russian Federation. Assessing the health system in Serbia In November 2016 and April 2017, WHO expert teams undertook two assessment visits to Serbia to continue an assessment of the country’s health system and its ability to accelerate gains in key NCD outcomes. The 2017 visit was carried out with national experts and aimed to produce pragmatic and actionable policy recommendations. It focused on the coverage of individual services related to the assessment and management of cardiovascular diseases, diabetes and stroke, as well as early detection and treatment of cancer. Health system service delivery for NCD patients was assessed, including current barriers and challenges but also opportunities to overcome existing obstacles and improve coordination across health service providers. The visit consulted a range of key stakeholders, including representatives of a health insurance fund, the medicines agency and a school of public health. Field visits to west and central Serbia provided insight into local primary health care clinics, institutes of public health and secondary and tertiary care hospitals. and management are well known, but implementation is variable and often not scaled up, despite the fact that early detection and treatment can significantly reduce morbidity, improve quality of life and reduce costly care at later stages for many NCDs. Managing NCDs can unlock enormous health and economic gains, but taking a comprehensive approach to the management of NCDs presents a challenge for health systems. The ageing of the population and the escalation of health care costs increase the urgency of this task. The term “management” covers coordinating the full range of measures to prevent, detect, screen and treat NCDs. It involves treating people with NCDs or at high risk of them, and it includes palliative care. Good management helps to prevent complications in patients with NCDs, reduces the need for hospitalization and avoids costly high-technology interventions – and premature deaths. intervention (SBI) programmes, WHO developed a training manual entitled WHO alcohol brief intervention training manual for primary care.18 The manual aims to support comprehensive training in SBIs for primary health care professionals. SBIs involve assessing a patient’s level of alcohol consumption through, for example, the Alcohol Use Disorders Identification Test, followed by a brief intervention to motivate behaviour change. The NCD Office supported a comprehensive consultation to produce a Russian version of the manual that would work in the context of Russian-speaking countries. Experts from the Russian Federation’s National Research Centre for Preventive Medicine, the Research Institute on Addictions and V. Serbsky Federal Medical Research Centre of Psychiatry and Narcology were closely involved in adapting and testing the new toolkit and manual. It was developed in expert meetings in 2016, and was tested in pilot training workshops in the Russian Federation, Serbia and Uzbekistan. Management NCDs account for a massive 77% of the disease burden in the WHO European Region, and this places major stresses on clinical services. NCDs are well studied and understood, and cost-effective interventions for NCD prevention 28 A comprehensive approach reduces the NCD burden by integrating health promotion, disease prevention and chronic care management, responding to acute episodes of illness and providing rehabilitation and palliative care when needed. Cancer Cancer causes 20% of deaths in the WHO European Region and is the most important cause of death and morbidity after cardiovascular disease. Moreover, in almost half the countries in the Region it has now become the main cause of death. WHO supports countries in implementing the four basic components of cancer control – prevention, early detection, diagnosis and treatment, and palliative care. Cancer is preventable in many cases thanks to healthy lifestyles. Early detection and adequate treatment substantially increase the chance of cure, or increase survival time and quality of life. Inspiration tour to North Karelia In 1972 the region of North Karelia in eastern Finland had the highest rate of coronary heart disease in the world. Then the North Karelia Project was set up. During the 40-year period from 1972 to 2012, coronary heart disease mortality in North Karelia decreased by a massive 82% among working-age men and 84% among women. In April 2017 a group of 28 professionals and representatives of health authorities from eastern Europe and central Asia went on a two-day study trip to North Karelia to see how Finland had achieved such impressive NCD outcomes. The Project is a far-reaching community-based intervention that reduces coronary heart disease mortality by encouraging healthier habits and cutting down on risk factors such as high cholesterol intake and smoking. It involves as many different sectors of the community as possible and communicates healthier habits in a simple, straightforward fashion. The Project, which is still active, has two slogans: “Face-to- face communication” and “Find common interests”. The group visited businesses, schools, health service locations and nongovernmental organizations and members returned to their countries with new ideas and inspiration. The workshop was supported by the Government of the Russian Federation under the technical leadership of the NCD programme of the WHO Regional Office for Europe. European NCD experts learning from the experience of North Karelia in successfully reducing cardiovascular disease mortality among working-age men and women 29 Package of essential NCD interventions for primary health care in low-resource settings (PEN) WHO PEN comprises four clinical practice protocols for early detection of NCDs and their diagnosis using inexpensive technologies, Improving palliative care services in the Russian Federation Populations around the world are ageing and more people are living with the effects of serious chronic illness towards the end of life. In March 2017 a team of WHO experts, led by the WHO Regional Office for Europe, conducted a visit to the Russian Federation to review palliative care services in the country. The Russian Ministry of Health invited the team to share their views and recommendations for improving the quality and accessibility of palliative care services with them and a group of national experts from four departments key to the organization of palliative care. During three intensive days the group explored policies and regulations, training and human resources, service delivery, research and funding. Together they toured several hospice services in Moscow and the Moscow region, and networked to ensure cooperation in palliative care in the future. “I am taking many new ideas home with me from this trip. The importance of collaboration between different sectors is perhaps the most essential. At home we focus only on treatment, and all available funds go to treatment. We need activities that direct attention to risk factors,” Roza Dzhakipova, National Coordinator of Noncommunicable Diseases in Bishkek, Kyrgyzstan, participant of the North Karelia tour in Finland Workshop on cancer screening and early diagnosis on limited resources A workshop led by the cancer programme of the WHO Regional Office for Europe on the early detection of cancer was held in December 2016 at the WHO Collaborating Centre for cancer early detection and screening in Turin, Italy. It focused on key elements of cancer screening and early diagnosis, in particular monitoring and evaluation and ensuring quality. Fifteen participants from Albania, Azerbaijan, Belarus, Kazakhstan, Montenegro, the Republic of Moldova, Serbia, Uzbekistan and the West Bank and Gaza Strip engaged with nine international experts and exchanged experiences. Improving patient pathways and speed of diagnosis for people with symptoms are a cost-effective way to diagnose cancer at an earlier stage. When a screening programme is introduced, diagnosis and treatment services must be ready to follow up appropriately those people who screen positive. Feedback from participants at the end of the workshop was very positive. They particularly appreciated expert guidance on how to introduce or improve early diagnosis and screening programmes within the available resources. non-pharmacological and pharmacological approaches for modification of NCD risk factors and affordable medications for prevention and treatment of NCDs. Workshops held in Uzbekistan in May 2016 (attended by representatives from 10 countries) and in Finland in March 2017 (14 countries) brought together teams from the different countries implementing PEN to share experience and skills on evidence- based strategies for clinical guideline implementation, quality-assurance systems, training and education, and monitoring and evaluation of impact, including economic impact. The 2017 workshop was held back- to-back with a study tour of North Karelia, Finland. WHO assisted Kyrgyzstan, Tajikistan and Uzbekistan with the implementation of PEN protocols, and worked with other countries to strengthen cardiovascular risk assessment and management in primary health care in general. Through a grant from the Government of the Russian Federation, WHO was able to convene three meetings during 2015–2017 for countries interested in working further in this area and sharing experience. Review of heart attack and stroke services Funded by a voluntary donation from the Government of the Russian Federation, and under the technical leadership of the NCD programme of the WHO Regional Office for Europe, WHO works to scrutinize the organization, delivery, utilization and performance of heart attack and stroke services, and provides recommendations to governments on prehospital care, acute care, secondary prevention and rehabilitation functions. This work has resulted in two WHO reports in Russian and English. 30 Review of acute care and rehabilitation services for heart attack and stroke in Belarus and Kyrgyzstan As part of an exploration of premature mortality, the WHO review in Belarus was undertaken in September 2016.20 It found that, although health systems in Belarus are in transition, significant progress and investment in infrastructure and human resources has already been made. Geographical disparities exist, however, and regional networks need to be developed further, along with better management of risk factors, updated drug formularies and guidelines, and a more patient-centred approach. Cardiovascular diseases are responsible for half the deaths in Kyrgyzstan, and are a major theme of the national health reform programme. A WHO review in October 2016 found gaps in resources and infrastructure, design of services, fragmented clinical pathways and networks and limited performance management.21 There was also a growing gap between the public and the private sectors, and between locations within and outside the capital, in what is provided and what changes are possible. A more strategic approach and roadmap for the development of these services could capitalize on the strengths and upcoming opportunities. The main messages were to manage the existing resources effectively; design the system and direct further investment; and demonstrate success. Cardiovascular diseases, particularly heart attacks and strokes, are major killers for both men and women, but can also be chronic diseases that many millions have to endure. They make a huge call on health system resources. The results of these reviews, carefully calibrated for the national context, will be used to strengthen the organization and delivery of acute care and rehabilitation services for heart attacks and strokes. While focusing on preventing NCDs, WHO will also ensure that countries share the progress they are making in responding to these devastating diseases. Further work is now focused on developing a cardiovascular disease roadmap with the support of funding from the Government of the Russian Federation. Consuming a healthy diet, including fruit and vegetables, helps prevent a range of noncommunicable diseases and conditions. 31 Scientific expertise and collaboration The NCD Office works closely with experts from the Russian Federation on a whole range of NCD activities, including in-country and intercountry activities, assessments, surveys, workshops, technical support and training from a range of Russian Federation institutions: • National Research Centre for Preventive Medicine; • V. Serbsky Federal Medical Research Centre for Psychiatry and Narcology; • Federal Research Institute for Health Organization and Informatics; • I.M. Sechenov First Moscow State Medical University; • Federal Almazov North-West Medical Research Centre; • National Medical Research Radiological Centre; • Pulmonology Research Institute; • Federal Research Centre of Nutrition, Biotechnology and Food Safety; and • Endocrinology Research Centre. Some of these are already WHO collaborating centres. Their experts make a crucial difference in the task of combating NCDs in the European Region. In addition to Russian consultants, the NCD Office works closely with WHO Regional Office for Europe to bring together other leading international minds by organizing international conferences and meetings that give participants an opportunity to share knowledge, experience, challenges and successes; and by collaborating with world experts to develop training courses. It also convenes international expert groups to analyse and synthesize the best available evidence from around the world to provide new perspectives and approaches, develop guidelines and recommendations and conduct innovative studies that will close the gaps that currently exist in the research on NCD prevention and control. Scientific centres of excellence and their experts from the Russian Federation are highly involved and make a major contribution to WHO’s work on NCDs across the European Region. 32 Office contacts WHO European Office for the Prevention and Control of Noncommunicable Diseases 9 Leontyevsky Pereulok 125009 Moscow, Russian Federation Email: NCDoffice@who.int Website: http://www.euro.who.int/en/NCDoffice Conclusion In the first three years of its existence the work on NCDs funded by the Government of the Russian Federation has made a serious global impact and has harnessed the knowledge of NCD experts from all over the world; strengthened NCD surveillance systems; supported countries in the development and implementation of crucial policies to prevent and control NCDs; inspired new approaches; disseminated evidence about successes and lessons learned; trained hundreds of professionals in policy, surveillance, prevention and management; and brought about concrete national assessments and plans. It continues to support countries as they work towards achieving their global goals on NCD reduction, and has contributed to the major progress made in the Region as it promises to exceed SDG 3.4. Most importantly, it continues to see a gratifying increase in interest in and understanding of how to prevent and control NCDs. The targets and commitments that drive the work of the NCD Office are all focused on one thing – the health of the people in the WHO European Region. References 1. Sustainable Development Goals [website]. New York: United Nations; 2017 (https://sustainabledevelopment.un.org/sdgs); NCD Global Monitoring Framework [website]. Geneva: World Health Organization; 2017 (http:// www.who.int/nmh/global_monitoring_framework/en/); Health 2020: the European policy for health and well-being [website]. Copenhagen: WHO Regional office for Europe; 2017 (http://www.euro.who.int/en/health- topics/health-policy/health-2020-the-european-policy-for-health-and-well- being), all accessed 1 November 2017. 2. Monitoring noncommunicable disease commitments in Europe. Theme in focus: progress monitor indicators. Copenhagen: WHO Regional Office for Europe; 2017 (http://www.euro.who.int/en/health-topics/noncommunicable- diseases/pages/who-european-office-for-the-prevention-and-control- of-noncommunicable-diseases-ncd-office/publications-and-tools/ monitoring-noncommunicable-disease-commitments-in-europe.-theme-in- focus-progress-monitor-indicators-2017, accessed 1 November 2017). 3. Montevideo Roadmap 2018–2030 on NCDs as a sustainable development priority. Geneva: World Health Organization; 2017 (http://www.who.int/ mediacentre/news/releases/2017/reduce-noncommunicable-diseases/en/, accessed 1 November 2017). 4. Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013–2020. Geneva: World Health Organization; 2013 (http:// www.who.int/nmh/events/ncd_action_plan/en/, accessed 1 November 2017). 5. Moscow Declaration: commitment to action, way forward. Geneva: World Health Organization; 2011 (http://www.who.int/nmh/events/moscow_ ncds_2011/conference_documents/en/, accessed 1 November 2017). 6. EUR/RC66/11: Action plan for the prevention and control of noncommunicable diseases in the WHO European Region. Copenhagen: WHO Regional Office for Europe; 2016 (http://www.euro.who.int/en/ about-us/governance/regional-committee-for-europe/past-sessions/66th- session/documentation/working-documents/eurrc6611-action-plan-for- the-prevention-and-control-of-noncommunicable-diseases-in-the-who- european-region, accessed 1 November 2017). 7. European Food and Nutrition Action Plan 2015–2020. Copenhagen: WHO Regional Office for Europe; 2015 (http://www.euro.who.int/en/publications/ abstracts/european-food-and-nutrition-action-plan-20152020); Physical activity strategy for the WHO European Region 2016–2025. Copenhagen: WHO Regional Office for Europe; 2016 (http://www.euro.who.int/en/ publications/abstracts/physical-activity-strategy-for-the-who-european- region-20162025); European action plan to reduce the harmful use of alcohol 2012–2020. Copenhagen: WHO Regional Office for Europe; 2012 (http://www.euro.who.int/en/health-topics/disease-prevention/alcohol-use/ publications/2012/european-action-plan-to-reduce-the-harmful-use-of- alcohol-20122021); WHO Framework Convention on Tobacco Control [website]. Geneva: World Health Organization; 2017 (http://www.who.int/ fctc/en/), all accessed 1 November 2017. 8. Prevention and control of noncommunicable diseases in Kyrgyzstan: the case for investment. Copenhagen: WHO Regional Office for Europe; 2017 (http://www.euro.who.int/en/countries/kyrgyzstan/publications/prevention- and-control-of-noncommunicable-diseases-in-kyrgyzstan.-the-case-for- investment-2017, accessed 1 November 2017). 9. Key considerations for the use of law to prevent noncommunicable diseases in the WHO European Region. Copenhagen: WHO Regional Office for Europe; 2017 (http://www.euro.who.int/en/health-topics/ disease-prevention/nutrition/publications/2017/key-considerations-for-the- use-of-law-to-prevent-noncommunicable-diseases-in-the-who-european- region-2017, accessed 1 November 2017). 10. Adolescent obesity and related behaviours: trends and inequalities in the WHO European Region, 2002–2014. Copenhagen: WHO Regional Office for Europe; 2017 (http://www.euro.who.int/en/health-topics/ disease-prevention/nutrition/publications/2017/adolescent-obesity- and-related-behaviours-trends-and-inequalities-in-the-who-european- region,-20022014, accessed 2 November 2017). 11. Monitoring food and beverage marketing to children via television and the Internet. Copenhagen: WHO Regional Office for Europe; 2017 (http://www.euro.who.int/en/health-topics/disease-prevention/nutrition/ publications/2017/monitoring-food-and-beverage-marketing-to-children- via-television-and-the-internet-2017, accessed 2 November 2017). 12. Towards more physical activity in cities. Copenhagen: WHO Regional Office for Europe (in press). 13. Newly Independent States: health impact of tobacco control policies [website]. Copenhagen: WHO Regional Office for Europe; 2017 (http:// www.euro.who.int/en/health-topics/disease-prevention/tobacco/data-and- statistics/newly-independent-states-health-impact-of-tobacco-control- policies, accessed 2 November 2017). 14. Tobacco Control Playbook [website]. Copenhagen: WHO Regional Office for Europe; 2017 (https://tobaccoplaybook.net/en/index.html, accessed 2 November 2017). 15. Tobacco control: a comprehensive approach at country level in the Russian Federation. Copenhagen: WHO Regional Office for Europe; 2017 (http:// www.euro.who.int/en/countries/russian-federation/publications/tobacco- control-a-comprehensive-approach-at-country-level-in-the-russian- federation-2017, accessed 2 November 2017). 16. Alcohol labelling: a discussion document on policy options. Copenhagen: WHO Regional Office for Europe; 2017 (http://www.euro.who.int/en/ health-topics/disease-prevention/alcohol-use/publications/2017/alcohol- labelling-a-discussion-document-on-policy-options-2017, accessed 2 November 2017). 17. Alcohol as a public health issue in Croatia: situation analysis and challenges. Copenhagen: WHO Regional Office for Europe; 2017 (http://www.euro. who.int/en/health-topics/disease-prevention/alcohol-use/publications/2017/ alcohol-as-a-public-health-issue-in-croatia-situation-analysis-and- challenges-2017, accessed 2 November 2017). 18. WHO alcohol brief intervention training manual for primary care. Copenhagen: WHO Regional Office for Europe; 2017 (http://www.euro. who.int/en/health-topics/disease-prevention/alcohol-use/publications/2017/ who-alcohol-brief-intervention-training-manual-for-primary-care-2017, accessed 2 November 2017). 19. Alcohol taxation policy in Kyrgyzstan. Copenhagen: WHO Regional Office for Europe; 2017 (http://www.euro.who.int/en/health-topics/disease- prevention/alcohol-use/publications/2017/alcohol-taxation-policy-in- kyrgyzstan-2017, accessed 3 November 2017). 20. Review of acute care and rehabilitation services for heart attack and stroke in Belarus. Copenhagen: WHO Regional Office for Europe; 2017 (http:// www.euro.who.int/en/countries/belarus/publications/review-of-acute-care- and-rehabilitation-services-for-heart-attack-and-stroke-in-belarus-2017, accessed 2 November 2017). 21. Review of acute care and rehabilitation services for heart attack and stroke in Kyrgyzstan. Copenhagen: WHO Regional Office for Europe; 2017 (http:// www.euro.who.int/en/countries/belarus/publications/review-of-acute-care- and-rehabilitation-services-for-heart-attack-and-stroke-in-kyrgyzstan-2017, accessed 2 November 2017). 33 34 14 The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. Member States Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czechia Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan The former Yugoslav Republic of Macedonia Turkey Turkmenistan Ukraine United Kingdom Uzbekistan WHO/EURO:2017-3288-43047-60244 World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 Email: euwhocontact@who.int Website: www.euro.who.int