Introduction

Globally, Non-Communicable Diseases (NCDs) are the main cause of death and represent a threat to all nations.¹ They financially impact individuals, families, communities and governments, due to premature deaths, disability, treatments and hospitalizations.²

Annually, NCDs are responsible for over 70% of all deaths worldwide (41 million), of which 15 million are premature deaths (people between the ages of 30 and 69).¹ The burden of NCDs is higher in low- and middle-income countries, accounting for approximately 78% of the total mortality.¹ In Brazil, in 2019, overall mortality due to these diseases corresponded to about 74% of all deaths (975,400 deaths)¹ and 71% of the total disability-adjusted life years (DALYs).³ Premature deaths, in 2017, corresponded to 41.3% (556,639).⁴

These diseases are multifactorial, however, the main causes include modifiable risk factors (RFs), such as tobacco use, harmful use of alcohol, physical inactivity and unhealthy diets. Adding to these, there are underlying social determinants that impact the increase and severity of NCDs and their RFs.^5,6

Several national and international initiatives have been promoted, in an effort to reduce the impact of NCDs. In September 2011, the High Level Meeting on Prevention and Control of Non-communicable Diseases of the United Nations (UN) was held. Its aim was to discuss the global commitments in terms of NCDs, which resulted in a political declaration in which all member states made a commitment to detain the increase of these diseases, by means of preventive actions regarding their main RFs and ensuring adequate attention to healthcare.⁶ It is worth highlighting that, in that meeting, was presented the 2011-2022 Strategic Action Plan to Tackle Non-communicable Diseases (NCDs) in Brazil.⁶ In 2013, the World Health Organization (WHO) approved the Global Action Plan for the Prevention and Control of NCDs, which contains the targets for reducing these diseases and their RFs by 2025, as well as the monitoring framework to track their implementation.⁷ In 2015, the UN also included strategies and targets to reduce the prevalence and RFs for NCDs, which will be monitored until 2030.⁸ In the Americas, the 2014-2019 Strategic Plan of the Pan American Health Organization (PAHO), defined the collective priorities and specified the results to be achieved during the specified period.⁹ Box 1 presents the targets for tackling the NCDs, according to the four plans cited above.

Brazil implemented an NCDs Surveillance system, by implementing different population surveys, such as the National Health Survey (Pesquisa Nacional de Saúde - PNS), providing means to ascertain the burden of these diseases, as well as their RFs and protection burden, in order to support planning, control, prevention and treatment actions, along with evaluation processes.¹⁰ In this sense, it is essential to monitor the agreed-upon targets for coping with NCDs and their RFs and, thus, to assess their reach and advancement, in addition to revising strategies when needed.

The aim of this study was to monitor the achievement of the action plans for the prevention and control of Non-Communicable Diseases agreed-upon targets.

Methods

Results

In the 2013 PNS 60,202 adult individuals were assessed, and 88,531 in the 2019 PNS.

Tables 1 and 2 present the prevalence of the indicators in 2013 and 2019 for the total population and according to sex, respectively. Regarding harmful alcohol consumption, the prevalence for the total population was 13.6% (95%CI 13.1;14.2) in 2013 and 17.1% (95%CI 16.6;17.5) in 2019, with an increase of 25% (PR = 1.25; 95%CI 1.19;1.31). Therefore, the 10% reduction target was not achieved.

Insufficient physical activity reduced 12% (PR = 0.88; 95%CI 0.86;0.90), from 45.7% (95%CI 44.9;46.5) in 2013 to 40.3 % (95%CI 39.6;40.9) in 2019. Hence, the 10% reduction target was attained for the total population. However, when considering sex, male individuals reduced insufficient physical activity by only 10%.

Tobacco consumption went from 14.9% (95%CI 14.4;15.4) in 2013 to 12.8% (95%CI 12.4;13.2) in 2019, with a reduction of 14% (PR = 0.86; 95%CI 0.82;0.90); therefore, the reduction target of 30% for tobacco use was not achieved.

Mean salt intake, which was 9.3g/day (95%CI 9.27;9.41) in 2013, was not measured in 2019, which made it impossible to monitor the target of reducing salt consumption by 30% until 2025. In addition, the prevalence of measured hypertension was 22.8% (95%CI 22.1;23.4) in 2013 and, as occurred with salt consumption, there was no measurement in 2019. In this case, there are only the self-reported prevalences in 2013 and 2019, which were 21.4% (95%CI 20.8;22.0) and 23.9% (95%CI 23.5;24.4), respectively, representing an increase of 12% (PR = 1.12; 95%CI 1.08;1.16). According to the self-report method, the goal of reducing the prevalence of hypertension by 25% would not be achieved. Likewise, the prevalence of diabetes in 2013, measured by glycated hemoglobin and the use of medications, showed a prevalence of 8.4% (95%CI 7.6;9.1), however, it was not measured in the same way in 2019. When evaluating the self-reported prevalence, there was an increase of 24% (PR = 1.24; 95%CI 1.16;1.33), from 6.2% (95%CI 5.9;6.8) in 2013 to 7.7% (95%CI 7.4;8.0) in 2019. Thus, the aim of halting the rise of diabetes was not attained.

Overweight and obesity increased 6% (56.9% in 2013 and 60.3% in 2019; PR = 1.06; 95%CI 1.01;1.11) and 24% (20.8% in 2013 and 25.9% in 2019; PR = 1.24 95%CI 1.08;1.43), respectively, and therefore it was not possible to achieve the target of these indicators. On the other hand, the target of increasing the number of eligible persons receiving drug therapy and counseling to 50% was attained in 2013, as the prevalence was 51.2%. The target of achieving a 70% coverage for Pap smears in women aged 30 to 49 years, once or more in their lifetime, was also achieved in 2013, with a coverage of 79.4% (95%CI 78.3;80.3%).

Figure 1 shows the prevalence for the indicators in 2013 and 2019, according to level of education. The targets for reducing harmful use of alcohol, tobacco use, high blood pressure, diabetes, overweight and obesity were not attained in any stratum. Moreover, the goal of reducing physical inactivity was not achieved in the population with no schooling/incomplete primary education and complete primary education/incomplete secondary education.

Figure 1 Prevalence of the indicators for monitoring the targets of the plans for tackling Non-Communicable Diseases (NCDs) in the Brazilian adult population, by level of education, National Health Survey (PNS), 2013 (n=60,202) and 2019 (n=88,531) 

When analyzing the targets according to the Brazilian regions, it is found that no region met the targets for alcohol abuse, high blood pressure, diabetes and tobacco use. Reducing physical inactivity by 10% was not achieved in the North and Northeast regions (Figure 2). Lastly, in terms of halting overweight and obesity, these targets were not measured considering the regions, only Brazil in its entirety.

Figure 2 Prevalence of the indicators for monitoring the targets of the plans for tackling Non-Communicable Diseases (NCDs) in the Brazilian adult population, by geographic region, National Health Survey (PNS), 2013 (n = 60,202) and 2019 (n = 88,531) 

Discussion

There has been progress and some of WHO global plan targets may have been attained, namely, reduction of physical inactivity and increased cervical cancer screening (Pap smear) coverage. Conversely, the target for reducing the harmful use of alcohol was not attained, on the contrary, the prevalence increased. In terms of tobacco use, even though the prevalence declined, the target was not achieved. In addition, considering the data in this study, the target of halting the rise of high blood pressure, diabetes, overweight and obesity might not be attained by 2025.

Some indicators were only measured in 2013 (salt/sodium intake, measured blood pressure, measured diabetes by means of laboratory tests, drug therapy and cervical cancer screening coverage), thus, comparing the results is unfeasible. In the 2013 survey, sodium intake was shown to be high, therefore, its reduction will hardly be achieved. When stratifying by sex, education and region, inequalities were observed, thus, progressing equitably and providing improvements to all segments of the population turns out to be challenging.

Alcohol use increased in both sexes for all levels of education and Brazilian regions. To try to reverse this scenario, some legislative measures were implemented in Brazil, such as the prohibition of the consumption of alcoholic beverages by automotive vehicle drivers, established through the “Lei Seca” (“Dry Law” or Prohibition Law) in 2008, and the New Prohibition Law in 2012, which increased the amount of the fine.¹⁴ Such measures resulted in decreased drinking and driving prevalence.¹⁴ However, there is still progress to be made in terms of the regulatory framework for alcohol in the country, especially in relation to the prohibition of beer advertising, considering that beer is not included in the marketing restriction because its alcohol content is below 13 degrees GL (Gay-Lussac).¹⁴

In the present study, even though a reduction in physical inactivity has been observed, its prevalence is still high, being one of the leading modifiable risk factors for NCDs, which negatively affects people’s mental health and life quality.^1,15 In this respect, the Brazilian National Health Promotion Policy and the Strategic Action Plan to Tackle Non-communicable Diseases elected physical activity encouragement as its priority action and in 2011, the Health Gym Program (Programa Academia da Saúde) was criated,¹⁶ which allowed for an increase in physical activity and, consequentially, an improvement of the quality of life and health of the Brazilian population.¹⁷

Combating smoking has been considered successful, and Brazil has become an international reference in this respect. The advances have been attributed to the regulatory measures that have been adopted in the past years, such as the ban on smoking in public spaces, control of advertising and sponsorships, cigarette price increases, warning labels and images on cigarette packs, among others.¹⁸ In 1989, Brazil had a very high smoking prevalence (34.8%),¹⁹ in contrast, in the following years the tendency was a decline.²⁰ In this regard, this study showed a prevalence of 12.8% in 2019. However, in order to achieve the 30% reduction target, in accordance with WHO Global Action Plan, restrictive regulatory measures must be accelerated.

The target of a 30% reduction in salt intake although not measured in 2019, is not expected to be reached. Important initiatives are highlighted, such as the launch of the Dietary Guidelines for the Brazilian Population (Guia Alimentar para a População Brasileira) in 2014²¹ and agreements to reduce sodium in processed foods.²² Nevertheless, if new regulatory measures are not effectively implemented, it is highly unlikely that the target will be attained. In this context, it is also worth highlighting the increase in obesity and, once again, the urgency of advancing in regulatory policies such as taxation of ultra-processed foods and regulation of food advertising to children, in addition to subsidies for the production of healthy products.²³

The indicator related to drug therapy to prevent heart attacks and strokes, although not measured in 2019, had already been reached in 2013. Several initiatives implemented between 2011 and 2015 can explain this fact⁶ redefinition of the Care Network for People with NCDs (Rede de Atenção às Pessoas com DCNTs); the National Program for Improving Access and Quality of Primary Care (Programa Nacional de Melhoria do Acesso e da Qualidade); the Acute Myocardial Infarction Care (Atenção ao Infarto Agudo do Miocárdio); the Cerebrovascular Accident Care (Atenção ao Acidente Vascular Cerebral); the Popular Pharmacy Program; and the Better at Home Program (Programa Melhor em Casa), which aims to expand home care.²⁴ These actions strengthened the Brazilian National Health System (SUS) response capacity and expanded actions aiming to prevent and control these NCDs.

Strategies for tracking and early detection of cancer among women are beneficial and cervical cancer incidence, mortality and morbidity can be reduced by means of screening programs, health promotion actions, prevention, diagnosis and treatment.^25,26 SUS ensures universal and free access to cervical cytology and Pap smears. This study showed that this target had also been attained in 2013.

Social inequalities regarding the RFs of NCDs can be the result of lack of opportunity in accessing health promotion and prevention practices, education and services.²⁷ Populations with lower income and level of education, that live in poorer countries and regions, concentrate more NCDs and their RFs.²⁸ The SDGs targets highlight the importance of intersectoral policies for the reduction of poverty, and also of gender and race/skin color differences, aiming for simultaneous progress of all countries. A pivotal milestone of the SDGs was “Leave no one behind”.⁸ In this context, this study shows inequalities and, in general, all the indicators were worse in the population with low schooling and residing in less socioeconomically developed regions. Therefore, it is crucial for Brazil to advance in a concerted way, reducing inequalities among its regions, as well as those related to gender, race/skin color and education.

It is worth highlighting that the actions mentioned herein may have been discontinued due to Brazil’s economic and political crises (when austerity policies were implemented, such as the Constitutional Amendment No. 95 passed in 2016, freezing the budgets for social policies and health for 20 years, for instance), decrease of the gross domestic product and reduction of allocation of federal funds for health care to municipalities, which have thus affected the offer of health services.^25,26 These factors disrupted social protection policies, contributed to an increase in poverty, extreme poverty and infant mortality, besides worsening health indicators.^25,26 Austerity policies end up affecting the underprivileged and, as a consequence, intensify inequalities.²⁶ In addition, there was no progress in terms of regulatory measures, which were abandoned after 2016. It should be noted that tobacco product prices have not increased in the past years and that surveillance activities have not been prioritized. Countries that have invested in regulatory measures have had significant progress, as is the case of Mexico, that taxed ultra-processed foods and, consequently, achieved a decline of 10% in the consumption of soft drinks.²⁹

Among the limitations of this study, some indicators, such as measured blood pressure and biochemical measurements, were not collected in 2019, thus impairing the evaluation of such indicators in 2019, hence the use of self-reported data. Anthropometric measurements (weight and height), for the 2019 edition, were conducted in a subsample, allowing to evaluate overweight and obesity only at national level, not by region. Self-reported data can lead to under or overestimation of prevalences and generate less accurate estimates. Nevertheless, a study conducted with data from the city of Bambuí (state of Minas Gerais) cohort, aiming to determine the validity of self-reported diabetes and its determinants among elderly people, showed that self-reported data are reliable.³⁰

There have been advances and improvements in the reduction of smoking and physical inactivity, in the provision of essential medications and coverage of Pap smears. However, some targets will not be met by 2025. Even though NCDs have gained priority in global and national agendas, challenges still remain for the development of effective policies for their control and prevention, combined with the need of advancing legal and regulatory measures. In the comprehensive approach to NCDs, intersectoral articulations and the reduction of socioeconomic and health inequalities are of the utmost importance.