Reducing harm from risk factors – a modern and effective approach to increasing the quality of life and improving health


The (in?)VINCIBLE PANDEMICS report , which was presented to the media and the public on October 14th, offers scientific analysis and a pragmatic outlook at four of the main health risk factors that have reached pandemic proportions in our society – unhealthy eating, alcohol abuse, smoking and excessive use of digital devices.

The echoes of the COVID-19 pandemic are gradually fading away, but have opened the door even wider for the so-called hidden pandemics – our harmful habits with which we “live” for decades and which will continue to exist in the future. The mortality statistics in our country during COVID- 19 are alarming – Bulgaria is in 2nd place in the world in terms of deaths per capita due to the coronavirus. And the key reason for this is the high level of co-morbid cardiovascular, cancer, lung and metabolic diseases associated with the pandemic-scale risk factors. The COVID-19 pandemic is a turning point for “eye-opening” and realizing that our country must come up with a new, different perspective with a scientifically based strategy to reduce the harm from the risk factors in our lives and the environment – to achieve a better health status of the population and better preparedness for possible future unexpected health threats.

The authors’ team of the report includes recognized scientists and experts – Assoc. Professor Milena Georgieva, Prof. Georgi Momekov, Detelina Stamenova and Arkadi Sharkov* from various fields – molecular biology, epigenetics , toxicology, pharmacology, psychology, health economics. PanEuropa Bulgaria united their scientific thought and public responsibility with one common goal – increasing health awareness about the specific risk spectrum of each of the four harmful habits, based on which effective approaches are offered to reduce their harm. The experts appealed to public health professionals and politicians to include strategies and methods for reducing harm from risk factors in future national policies aimed at improving the health of the population and reducing the economic burden on the health system.

“In response to the avalanche-like health, economic, social and political crises that are overloading us, PanEuropa Bulgaria is committed as its priority to address the problems related to improving health status, health culture and quality of life. Because only a healthy nation can deal with economic, social and political crises” , said Gergana Passi, President of PanEurope .

The authors of the report ((in?)VINCIBLE PANDEMICS ” are united in their belief that due to national characteristics, culture, traditions and patterns of behavior, as well as the need to respect the health status of each individual, it is essential that people receive only reliable scientifically substantiated information in an understandable language. And the civilizational approach of respecting the right and freedom of choice should be the basis of the attitude towards all harmful habits that people practice. Prohibitions and imperative messages, such as “no” to “sweetened foods and drinks”, “no” to alcohol, “no” to tobacco, “no” to standing long in front of digital screens are clearly not working successfully. They probably remind of the damages, but do not significantly contribute to overcoming them. What would have a true effect of changing mindset and taking real steps, is a calm and clear communication about the degree of harm of each risk factor and advice on easy alternative approaches to reduce the harm from them.

Associate Professor Milena Georgieva from BAS (Bulgarian Academy of Science) presented data on overweight and obesity in EU and Bulgaria. According to her, an unhealthy diet, in combination with a sedentary lifestyle, combined with other risk factors, represents a major risk from an early age for the development of a number of chronic diseases, such as cardiovascular, cancer, diabetes and others. The topic of unhealthy eating as a serious risk factor is not new, but Associate Professor Milena Georgieva also offers a different view – the epigenetic aspect, i.e. a lifestyle such as diet, stress, bad habits and lack of physical activity leave a mark on the human body for future generations. The effects can multiply and may increase the adverse effect of these risks.

In determining the spectrum of food risk, what plays a role is the content of harmful ingredients, such as salt, sugar, fat, artificial additives, etc., and the degree of processing. “Definitely delineating the spectrum of risk for any single product is complex, but there are several science-based international systems using scoring and grading. For the purposes of achieving reduced risk, the principle the use is one – the lower the processing the products have undergone before reaching the table and the lower the content of harmful substances, the lower the risk to health. Vice versa – highly processed foods with a high content of sugar, salt, fat and other additives place them in the high risk spectrum ,” explained Associate Professor Georgieva and recommended approaches to reduce harm: pursuing a policy to ensure wide availability and affordable prices of less harmful food products; differentiated marketing and regulation of food products according to the degree of risk; incentives by the governments to the industry for investments in less harmful food products; industry communication of the risk/benefit paradigm; labeling of food products in accordance with their nutritional value, content of sugars, salt and other ingredients, as well as the degree of processing; support from business and the state for regular physical activity.

In his typical rhetorics, Prof. Georgi Momekov reminded that the human body is a magnificently lubricated machine, one of the most complex forms of life – the result of millennial adaptation to the changing conditions on the Earth. “Undoubtedly, regular food intake is an existential factor for the human organism – a fundamental fuel for this machine. Unlike food, alcohol and tobacco/nicotine are non-essential for the human body. However, they have been around for centuries. Their use is not related to the purely physical survival of mankind /as it is with food/, but they are related to other social and mental needs – pleasure. A small area in the brain is responsible for the connection between survival and pleasure: the reward system. Substances are released that suppress fear and give rise to satisfaction. In the Report, we claim that total prevention or cessation of drinking and smoking should remain the highest health goal, but we recognize that this is an ideal goal. In real life and from the point of view of science, it is just equally meaningful and appropriate to talk about reducing the harms of alcohol and tobacco, especially when science has proven that there are alternatives and it is possible. Prof. Momekovexplained.

Referring to alcohol, having the knowledge of pure ethyl alcohol (ethanol) content is key. The ethanol content in the three main ( most popular) beverages in a standard serving size is similar -it  is only in different concentration. The concentration of pure alcohol in beer is around 5%, 12% in wine and 40% in hard alcohol – the amount of ethanol in 300 ml of beer, 100 ml of wine and 30 ml of hard alcohol is the same. Moreover, the concept of “standard drink” varies from country to country. Despite the recommendations of the WHO for a standard of 10 g of ethanol in drinks and the wide acceptance of this standard in the EU, in Bulgaria one standard drink contains 20 g of ethanol. That means, Bulgarians drink more pure alcohol compared to a number of Europeans, despite the fact that local people may drink “moderately”, for example, one or two drinks a day and not every day. This places our country in 8th place in terms of ethanol consumption out of 217 countries in the world. Harm reduction approaches include educational initiatives on the harm of alcohol, namely on the amount of ethanol in alcoholic beverages, involvement of the alcohol and entertainment industry in information campaigns, promotion of non-alcoholic alternatives, clear labeling of the ethanol content of beverages, moderate consumption and avoidance of mixing alcohol and drugs and others.  

When we analyze and compare the level of risk from smoking and from other forms of tobacco and nicotine use, the factors determining the spectrum of risk for nicotine delivery are mainly two: the composition of the given product and the method of extracting nicotine (method of use). From a scientific point of view, the reason for practicing this unhealthy habit is nicotine – a hunger for pleasure and satisfaction encoded in the brain, but it is not the reason for the development of diseases. Of greater importance to the level of harmfulness of a given product is the method of extracting the nicotine – be it from NRT /nicotine replacement therapies/, from nicotine liquids vaporization or from tobacco, in which nicotine is a naturally contained element. When nicotine is extracted at zero temperature, the risk is the lowest, and when nicotine is extracted by combustion, numerous chemical reactions occur and smoke is formed. The smoke contains over 7000 harmful chemical elements, about 100 of them are dangerous due to their toxicity and carcinogenicity. Therefore, the highest exposure to harm is from smoking, because it burns and smoke is formed, which is inhaled, and the lowest  – from NRT. When heating and vaporizing nicotine liquids or tobacco, the formation of harmful substances is significantly lower than in smoke, which is why when determining the risk spectrum, these products stand in the lower risk zone. Harm reduction approaches include medical treatment, psychological support, individual and group therapies; replacing cigarettes or other smoking products with different other forms of tobacco or nicotine use that do not burn and the exposure to toxic, carcinogenic or other harmful substances is lower; eliminating passive smoking for non-smokers by replacing smoking with smokeless/non-combustible products, introducing risk-based regulation, marketing and labeling of products, as well as appropriate fiscal measures for the different types of products according to the level of risk.

Compared to the above risk factors – unhealthy diet, alcohol abuse and smoking, the problematic use of electronic devices is a relatively new risk factor. The Internet provides useful information – aims at improving our quality of life, education, enables staying in touch with loved and close ones, easier navigations, directions, shopping, banking, increased workplace productivity, health status tracking, and more. But screen time has explosive growth in the last decade, and today 5.3 billion people use digital devices daily (nearly 70% of the world’s population). COVID-19 has led to a 70% increase in internet usage. On average, 50% of the time is spent in social media. The average duration of time in front of the screens is 5 hours per day. “The consequences of excessive use of digital devices are actively researched, but it is abundantly clear that the spread is massive and begins at a very early age in uncontrollable proportions and it is difficult to self-control in adults too. The problematic use of digital services often develops into addictions and leads to disorders, along with eye diseases, a sedentary lifestyle and alienation – all of these multiply the risk of physical and mental illnesses ,” said psychologist Detelina Stamenova . Harm reduction approaches include involvement and education of parents, pediatricians, and teachers who have an impact on children’s behaviour; regular screening for myopia, obesity, spine problems, mental problems; careful digitization of the educational process; more teamwork and traditional school activities and physical activity; introducing rules on screen time, notifications, paid services and introducing requirements for game developers to cut playing time after a certain period of time.

Dealing with the above risk factors has a serious economic cost . “The financial burden and challenges facing the health system have increased, and the post-pandemic future after COVID-19 hides health crises to which we need to find a sustainable response ,” said Arkadi Sharkov and further explained: “Even before the COVID-19 pandemic, Bulgaria was among the EU member states with the most negative data in terms of life expectancy, preventable mortality and DALYs (years lost as a result of illness or premature death). Scientifically based analyzes of the risk spectrum of harmful behaviors and approaches to reducing their harm will also reduce the economic burden they have on Bulgaria.” According to the report, numerous health and economic studies confirm the existence of a relationship between mortality, morbidity and economic growth. This affects the conditions for sustainable financial development of a given country, including the growth of productivity, education, birth rate, etc. The main chronic diseases that put pressure on health financing are cardiovascular, cancer and metabolic – all caused by the multiplication of harm from risk factors. Arkadi Sharkov gave an example that obesity alone is a huge burden on national economies due to the high medical costs associated with it. It puts great economic pressure on an already overburdened health care system, increasing the cost of providing health care services by almost 40% and the cost of treatment by more than 70%. Another example is that to overcome the consequences of smoking, health systems in individual countries pay between 0.1% and 1.1% of their GDP according to WB data, and these costs reach 2.5% of GDP according to other health economic studies. /In Bulgaria, this amount amounts to over 500 million euros/.

The (in?)VINCIBLE PANDEMICS report aims to raise awareness of widespread health risk factors by presenting the scientific view of the mechanisms leading to worsened health and offering recommendations for HARM REDUCTION. It focuses on the valuable knowledge that the post-COVID era now provides – targeted action to inform the population about the main risk factors and implement modern policies to either stop harmful habits or limit the harm from them, with a view to improving the way of life and the general health status of Bulgarians.

The full report can be found here.

* Team:

Associate Professor Milena Georgieva – Laboratory of Molecular Genetics, Institute of Molecular Biology – BAS, expert in genetics, epigenetics and aging biology, member of the Society of Clinical Epigenetics, Union of Scientists in Bulgaria and Federation of European Biochemical Societies.

Prof. Georgi Momekov – Chairman of the Bulgarian Scientific Society of Pharmacy and Head of the Department of “Pharmacology, Pharmacotherapy and Toxicology” at the Faculty of Pharmacy at the Sofia University.

Detelina Stamenova – psychotherapist, psychologist and sociologist, member of the Society of Psychologists in Bulgaria.

Arkadi Sharkov – macroeconomist, expert in healthcare economics, sustainable development and tax policy, part of the Expert Club For Economics and Politics (ECEP).