Abstract

Given the Constitutional Amendment 95 and the economic crisis, we discussed the possible effects of austerity measures on the achievement of the goals established for the control of chronic noncommunicable diseases (NCDs) in the country. The trends of NCDs and risk factors were analyzed, according to data from epidemiological surveys and mortality data from the Global Burden of Disease study. The resultsindicate a trend of stability in mortality rates by NCD in 2015 and 2016. Brazilians with low schooling, in general, have a higher prevalence of risk factors and a lower prevalence of protective factors. In the 2015-2017 period, previously favorable trends reversed for indicators such as fruit and vegetable consumption and physical activity, tobacco trends stabilized, and alcohol intake increased. In conclusion, should these trends be maintained, it is unlikely that Brazil will achieve the goals previously agreed upon with the World Health Organization and the United Nations to curb NCDs and their risk factors.

Noncommunicable diseases; Risk factors; Mortality; Austerity; Sustainable development

Introduction

Noncommunicable Diseases (NCD) are an immense challenge to human health and development. They account for about 36 million annual deaths ¹1. World Health Organization (WHO). Mortality and burden of disease. Noncommunicable Diseases (NCD) Country Profiles, 2014: Brazil [Internet]. Geneva: WHO; 2014. [cited 2014 Oct 29]. Available from: Available from: http://www.who.int/nmh/countries/bra_en.pdf?ua=1
http://www.who.int/nmh/countries/bra_en.... and can also lead to high rates of disability, causing suffering and material costs directly and indirectly to patients and their families, as well as generate essential demands on the health system’s costs ²2. World Health Organization (WHO). Health topics: Chronic diseases . Geneva: WHO; 2013. [cited 2014 Oct 29]. Available from: http://www.who.int/topics/chronic_diseases/en/
http://www.who.int/topics/chronic_diseas... ^,33. Bloom DE, Cafiero ET, Jané-Llopis E, Abrahams-Gessel S, Bloom LR, Fathima S, Feigl AB, Gaziano T, Mowafi M, Pandya A, Prettner K, Rosenberg L, Seligman B, Stein AZ, Weinstein C. The global economic burden of non-communicable diseases: report by the World Economic Forum and the Harvard School of Public Health. Geneva: World Economic Forum; 2011. [cited 2014 Oct 29]. Available from: http://www3.weforum.org/docs/WEF_Harvard_HE_GlobalEconomicBurdenNonCommunicableDiseases_011.pdf/
http://www3.weforum.org/docs/WEF_Harvard... .

Due to the magnitude of NCDs and the evidence that it is possible to advance in public policies to address them, in 2011, the United Nations held an international meeting on the subject, which resulted in the approval of the 2013-2020 Global Plan to Combat the NCDs ⁴4. World Health Organization (WHO). Global Action Plan for the Prevention and Control of NCDs 2013-2020 [Internet]. Geneva: World Health Organization; 2013. [cited 2014 Oct 29]. Available from: http://www.who.int/nmh/events/ncd_action_plan/en/
http://www.who.int/nmh/events/ncd_action... in 2013, and by 2015, in the inclusion of the theme in Agenda 2030 of the Sustainable Development Goals (SDG) by the United Nations ⁵5. United Nations. Agenda 2030 e nos Objetivos do Desenvolvimento Sustentável. ODS . [cited 2014 Oct 29]. Available from: http://www.agenda2030.org.br/
http://www.agenda2030.org.br/... .

In this context, in 2011, in the United Nations Assembly, Brazil launched the “Strategic Actions Plan for Coping with NCDs in Brazil, 2011-2022” ⁶6. Malta DC, Morais Neto OL, Silva Júnior JB. Apresentação do plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis no Brasil, 2011 a 2022. Epidemiol Serv Saude 2013; 20(4):425-438. and implemented in the last decade a NCD Surveillance system that allows the monitoring of national and global levels of NCDs, which was a breakthrough in NCD Surveillance in the country ⁷7. Stringhini S, Carmeli C, Jokela M, Avendaño M, Muennig P, Guida F, Ricceri F, d’Errico A, Barros H, Bochud M, Chadeau-Hyam M, Clavel-Chapelon F, Costa G, Delpierre C, Fraga S, Goldberg M, Giles GG, Krogh V, Kelly-Irving M, Layte R, Lasserre AM, Marmot MG, Preisig M, Shipley MJ, Vollenweider P, Zins M, Kawachi I, Steptoe A, Mackenbach JP, Vineis P, Kivimäki M; LIFEPATH consortium. Socioeconomic status and the 25 × 25 risk factors as determinants of premature mortality: a multicohort study and meta-analysis of 1·7 million men and women. Lancet 2017; 389(10075):1229-1237. .

There is also evidence that highlights the relevance of social determinants, particularly poverty, in the occurrence of NCDs, with the worst indicators recorded in the most vulnerable population ⁷7. Stringhini S, Carmeli C, Jokela M, Avendaño M, Muennig P, Guida F, Ricceri F, d’Errico A, Barros H, Bochud M, Chadeau-Hyam M, Clavel-Chapelon F, Costa G, Delpierre C, Fraga S, Goldberg M, Giles GG, Krogh V, Kelly-Irving M, Layte R, Lasserre AM, Marmot MG, Preisig M, Shipley MJ, Vollenweider P, Zins M, Kawachi I, Steptoe A, Mackenbach JP, Vineis P, Kivimäki M; LIFEPATH consortium. Socioeconomic status and the 25 × 25 risk factors as determinants of premature mortality: a multicohort study and meta-analysis of 1·7 million men and women. Lancet 2017; 389(10075):1229-1237.^,88. Pearce N, Ebrahim S, McKee M, Lamptey P, Barreto ML, Matheson D, Walls H, Foliaki S, Miranda JJ, Chimeddamba O, Garcia-Marcos L, Haines A, Vineis P. Global prevention and control of NCDs: Limitations of the standard approach. J Public Health Policy 2015; 36(4):408-425. . Studies on the impact of the 2008 financial crisis in Europe and the fiscal austerity measures implemented in several countries show essential effects on public health expenditure, deterioration of child and mental health, and increased heart diseases ⁹9. Parmar D, Stavropoulou C, Ioannidis JP. Health outcomes during the 2008 financial crisis in Europe: systematic literature review. BMJ 2016; 354:i4588.^,1010. Schramm JM, Paes-Sousa R, Mendes LVP. Políticas de austeridade e seus impactos na saúde: um debate em tempos de crises . Rio de Janeiro: Fiocruz; 2018 .

The austerity measures adopted in Brazil in the last period, consolidated with the approval of EC95 in 2016 ¹¹11. Brasil. Emenda constitucional nº 95, de 15 de dezembro de 2016. Altera o Ato das Disposições Constitucionais Transitórias, para instituir o Novo Regime Fiscal, e dá outras providências. Diário Oficial da União 2016; 15 dez. , generate unemployment and increased poverty and affect the health system and the entire social protection system. In this new context, it is essential to monitor the behavior of the risk factors agreed in the NCD coping plans to understand whether they were affected by these measures. Thus, this research note discusses the possible effects of fiscal austerity measures on achieving the goals established for the NCDs’ control in the country.

Methods

We analyzed trends in the prevalence of risk factors and chronic diseases that are consistent with the goals related to national and global commitments in tacklingNCDs ⁴4. World Health Organization (WHO). Global Action Plan for the Prevention and Control of NCDs 2013-2020 [Internet]. Geneva: World Health Organization; 2013. [cited 2014 Oct 29]. Available from: http://www.who.int/nmh/events/ncd_action_plan/en/
http://www.who.int/nmh/events/ncd_action...

5. United Nations. Agenda 2030 e nos Objetivos do Desenvolvimento Sustentável. ODS . [cited 2014 Oct 29]. Available from: http://www.agenda2030.org.br/
http://www.agenda2030.org.br/... ^-66. Malta DC, Morais Neto OL, Silva Júnior JB. Apresentação do plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis no Brasil, 2011 a 2022. Epidemiol Serv Saude 2013; 20(4):425-438. . Concerning the goal of reducing the NCD-related mortality rate, according to the WHO, four groups of causes are considered: cardiovascular diseases (I00-I99), respiratory diseases (J30-J98), neoplasms (C00-C97) and diabetes mellitus (E10-E14) ⁴4. World Health Organization (WHO). Global Action Plan for the Prevention and Control of NCDs 2013-2020 [Internet]. Geneva: World Health Organization; 2013. [cited 2014 Oct 29]. Available from: http://www.who.int/nmh/events/ncd_action_plan/en/
http://www.who.int/nmh/events/ncd_action... . We used the estimates of Global Burden of Disease (GBD) database of the Institute of Health Metrics and Evaluation (IHME), and the Ministry of Health’s Mortality Information System (SIM) is the primary source of GBD mortality information in Brazil. Sub-registries with ill-defined causes and garbage code have been adjusted and can be read in other publications ¹²12. GBD 2015 Mortality and Causes of Death Collaborators. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden Disease Study 2015. Lancet 2016; 388(10053):1459-1544. . Concerning the NCD Brazil Plan ⁶6. Malta DC, Morais Neto OL, Silva Júnior JB. Apresentação do plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis no Brasil, 2011 a 2022. Epidemiol Serv Saude 2013; 20(4):425-438. , the target of a 2% reduction in the premature mortality rate (30-69 years of age) by 2022 was assessed.

Regarding risk factors (RF), information from the Surveillance System for Risk and Protection Factors for Chronic Diseases by Telephone Inquiry (VIGITEL) was used for Brazilian capitals, carried out annually among adults aged 18 and over who have a landline. The VIGITEL 2010 data served as the baseline ¹³13. Brasil. Ministério da Saúde (MS). Vigitel Brasil 2017: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico . Brasília: MS; 2018. .

Goals established in the NCD Plan for 2022 and indicators measured between 2010 and 2017 in the Brazilian capitals

1. Obesity: to contain the growth of obesity in adults aged 18 years and over, according to self-reported weight and height data of VIGITEL for this population.

2. Alcohol: 10% reduction in the prevalence of alcohol abuse in adults, four or more doses in women and five doses or more in men in the last 30 days.

3. Tobacco use: 30% reduction of tobacco use prevalence in adults.

4. Physical activity: 10% increase in the prevalence of physical activity (PA), considering the weekly practice of 150 minutes of leisure time PA among adults in the week, regardless of the number of days.

5. Food: 10% increased prevalence of fruit and vegetable consumption, or consumption of 5 daily servings or more.

6. Two indicators of the global NCD coping plan were also inserted ⁴4. World Health Organization (WHO). Global Action Plan for the Prevention and Control of NCDs 2013-2020 [Internet]. Geneva: World Health Organization; 2013. [cited 2014 Oct 29]. Available from: http://www.who.int/nmh/events/ncd_action_plan/en/
   http://www.who.int/nmh/events/ncd_action... : to reduce arterial hypertension by 25%, and halt the growth of diabetes, both assessed by VIGITEL through the question “Did any doctor give you a diagnosis of high blood pressure or diabetes?” ¹³13. Brasil. Ministério da Saúde (MS). Vigitel Brasil 2017: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico . Brasília: MS; 2018. Prevalence was compared from 2010 to 2017, by years of schooling (0 to 8, 9 to 11 and 12 years and over). Differences between 2010 (baseline), 2014 and 2015 and 2017 were calculated, as well as the prevalence ratio by schooling levels, with 12 years and more as a reference (PR = 1.0) and Confidence Interval of 95% (95% CI) using Poisson Regression.

Results

The premature mortality rate standardized by NCD in 1998 was 477.6/100,000 inhabitants. In 2010, the NCD Brazil Plan baseline was 372.4/100,000 inhabitants, with a progressive decline of around 2% per annum in the period. In 2014, the rate was 344.9/100,000 inhabitants, in 2015, 341.8/100,000 inhabitants, and in 2016, 340.4/100,000 inhabitants. The annual decline in premature mortality rates standardized by NCD after the launch of the NCD Brazil Plan was: 2.0% (2011), 2.2% (2012), 1.7% (2013), 1.7% (2014), 0.9% (2015), and 0.4% (2016). Between 2015 and 2016, rates of cardiovascular diseases (261.8 and 261.0/100.000), chronic respiratory diseases (23.6 and 23.6/100,000), diabetes (24.8 and 25.2/100,000) and neoplasms (131.6 and 130.6) were stable ( Figure 1 ).

Regarding the prevalence of risk factors estimated annually by VIGITEL, it can be observed that the behavior in the period 2010-2014 is markedly different from that of 2015-2017. For example, alcohol abuse that had been reduced in the first period increased in the second, in the total and all levels of education. The consumption of fruits and vegetables that grew sharply in the first period decreased in the second, also in all levels of schooling. Physical activity increased in the first period and decreased in the following period in all levels of schooling. Tobacco use declined 23.4% in the first period and only 2.9% in the second, with an increased prevalence in the population with over nine years of schooling. Only obesity increased in the first period and maintained a stable prevalence in the second period, except among the more educated, where they increased the prevalence ( Table 1 ).

The population with the lowest educational level (0-8 years) usually has a higher prevalence of risk factors. Comparing the prevalence ratios (PR) of the population with low schooling (0-8 years) with that of over 12 years schooling, in 2017, the highest PR was found among smokers (PR = 1.8 IC95% 2.0), in the obese population (PR = 1.5, 95% CI 1.3-1.7), with hypertension (PR = 2.7, 95% CI 2.5-2.9), and with diabetes PR = 4.4; 95% CI 3.9-4.9). It is worth noting that in the population with diabetes, the PR increased by schooling level in the period – (2010: PR = 2.6, 95% CI: 2.2-3.1) and (2017: PR = 4.4, 95% CI 3.9 -4.9). The prevalence rates were lower for protective factors: physical activity (PR = 0.5, 95% CI 0.4-0.5), and intake of fruits and vegetables (PR = 0.6, 95% CI 0.5- 0.6) ( Table 1 ).

Discussion

Although NCD mortality trends have declined by more than 2 percent in the last decade and the early years of the NCD Coping Plan, the recent trend towards stabilization may be a consequence of a behavioral change of the risk factors and living conditions and access to services, affected by the economic and social crisis ¹⁰10. Schramm JM, Paes-Sousa R, Mendes LVP. Políticas de austeridade e seus impactos na saúde: um debate em tempos de crises . Rio de Janeiro: Fiocruz; 2018^,1414. Rasella D, Basu S, Hone T, Paes-Sousa R, Ocke´-Reis CO, Millett C. Child morbidity and mortality associated with alternative policy responses to the economic crisis in Brazil: A nationwide microsimulation study. PLoS Med 2018; 15(5):e1002570. . Given this behavior, the goal of reducing premature mortality due to NCDs of the Agenda 2030 (SDG) may not be met.

Brazil is experiencing a deep economic and political crisis with social programs cuts and deteriorating health sector performance ¹⁰10. Schramm JM, Paes-Sousa R, Mendes LVP. Políticas de austeridade e seus impactos na saúde: um debate em tempos de crises . Rio de Janeiro: Fiocruz; 2018^,1111. Brasil. Emenda constitucional nº 95, de 15 de dezembro de 2016. Altera o Ato das Disposições Constitucionais Transitórias, para instituir o Novo Regime Fiscal, e dá outras providências. Diário Oficial da União 2016; 15 dez. . Recent studies by Rasella et al. ¹⁴14. Rasella D, Basu S, Hone T, Paes-Sousa R, Ocke´-Reis CO, Millett C. Child morbidity and mortality associated with alternative policy responses to the economic crisis in Brazil: A nationwide microsimulation study. PLoS Med 2018; 15(5):e1002570. , point out that fiscal austerity measures may compromise health outcomes, especially among poor and vulnerable Brazilians.

The 2016 SIM data already indicate increased infant mortality, interrupting a cycle of more than twenty years of continuous decline ¹⁵15. Datasus. Sistema de Informação de Mortalidade. [acessado 2018 Ago 14]. Disponível em: http://www2.datasus.gov.br/DATASUS/index.php?area=0205&id=6937&VObj=http://tabnet.datasus.gov.br/cgi/deftohtm.exe?sim/cnv/obt10
http://www2.datasus.gov.br/DATASUS/index... ^,1616. FSP Mortalidade de crianças no Brasil aumentou após 15 anos de queda no índice. [acessado 2018 Maio 25]. Disponível em: https://noticias.uol.com.br/saude/ultimas-noticias/redacao/2018/05/26/corte-bolsa-familia-investimento-saude-mortalidade-infantil-estudo.htm
https://noticias.uol.com.br/saude/ultima... . The same is true of maternal mortality ¹⁵15. Datasus. Sistema de Informação de Mortalidade. [acessado 2018 Ago 14]. Disponível em: http://www2.datasus.gov.br/DATASUS/index.php?area=0205&id=6937&VObj=http://tabnet.datasus.gov.br/cgi/deftohtm.exe?sim/cnv/obt10
http://www2.datasus.gov.br/DATASUS/index... ^,1717. Mortalidade materna sobe, e Brasil já revê meta de redução para 2030. Sem cumprir compromissos de queda, país ainda teve alta de taxa em 2016. [acessado 2018 Ago 13]. Disponível em: https://www1.folha.uol.com.br/cotidiano/2018/08/mortalidade-materna-sobe-e-brasil-ja-reve-meta-de-reducao-para-2030.shtml
https://www1.folha.uol.com.br/cotidiano/... . Worth noting are increasing cases of vaccine-preventable diseases, such as measles and yellow fever, and declining vaccine coverage reflecting the deterioration of health services ¹⁸18. Doenças Transmissíveis. Casos crescem e índice de vacinação diminui . [acessado 2018 Ago 25]. Disponível em: http://temas.folha.uol.com.br/e-agora-brasil-saude/doencas-transmissiveis/casos-crescem-e-indice-de-vacinacao-diminui.shtml. FSP
http://temas.folha.uol.com.br/e-agora-br... ^,1919. SUS é mais do que uma política de saúde pública. Entrevista especial com Jairnilson Paim . [acessado 2018 Ago 14]. Disponível em: http://www.ihu.unisinos.br/581727-sus-e-mais-do-que-uma-politica-de-saude-publica-entrevista-especial-com-jairnilson-paim Revista ihu on-line
http://www.ihu.unisinos.br/581727-sus-e-... . Declining indicators reflect the austerity-related crisis, reduced investment in social programs, and increased poverty and vulnerability ¹⁰10. Schramm JM, Paes-Sousa R, Mendes LVP. Políticas de austeridade e seus impactos na saúde: um debate em tempos de crises . Rio de Janeiro: Fiocruz; 2018^,1414. Rasella D, Basu S, Hone T, Paes-Sousa R, Ocke´-Reis CO, Millett C. Child morbidity and mortality associated with alternative policy responses to the economic crisis in Brazil: A nationwide microsimulation study. PLoS Med 2018; 15(5):e1002570. .

The social determination of NCDs has already been pointed out in several studies ⁸8. Pearce N, Ebrahim S, McKee M, Lamptey P, Barreto ML, Matheson D, Walls H, Foliaki S, Miranda JJ, Chimeddamba O, Garcia-Marcos L, Haines A, Vineis P. Global prevention and control of NCDs: Limitations of the standard approach. J Public Health Policy 2015; 36(4):408-425.^,99. Parmar D, Stavropoulou C, Ioannidis JP. Health outcomes during the 2008 financial crisis in Europe: systematic literature review. BMJ 2016; 354:i4588. . The 2013 National Health Survey highlighted the weight of social inequalities in risk factors, since the prevalence adjusted for age and gender of them is notably higher among the less educated ²⁰20. Azevedo Barros MB, Lima MG, Medina LPB, Szwarcwald CL, Malta DC. Social inequalities in health behaviors among Brazilian adults: National Health Survey, 2013. Int J Equity Health 2016; 15(1):148.^,2121. Malta DC, Bernal RTI, Lima MG, Araújo SSC, Silva MMA, Freitas MIF, Barros MBA. Doenças crônicas não transmissíveis e a utilização de serviços de saúde: análise da Pesquisa Nacional de Saúde no Brasil. Rev Saude Publica 2017; 51(Supl. 1):4s. . Poorer populations tend to be more affected ⁸8. Pearce N, Ebrahim S, McKee M, Lamptey P, Barreto ML, Matheson D, Walls H, Foliaki S, Miranda JJ, Chimeddamba O, Garcia-Marcos L, Haines A, Vineis P. Global prevention and control of NCDs: Limitations of the standard approach. J Public Health Policy 2015; 36(4):408-425.

9. Parmar D, Stavropoulou C, Ioannidis JP. Health outcomes during the 2008 financial crisis in Europe: systematic literature review. BMJ 2016; 354:i4588.^-1010. Schramm JM, Paes-Sousa R, Mendes LVP. Políticas de austeridade e seus impactos na saúde: um debate em tempos de crises . Rio de Janeiro: Fiocruz; 2018^,1414. Rasella D, Basu S, Hone T, Paes-Sousa R, Ocke´-Reis CO, Millett C. Child morbidity and mortality associated with alternative policy responses to the economic crisis in Brazil: A nationwide microsimulation study. PLoS Med 2018; 15(5):e1002570.^,2222. Stuckler D, Basu S. A economia desumana: porque mata a austeridade . Lisboa: Editorial Bizâncio; 2014. in crisis contexts. This is also shown by the data evidenced here.

The evidence indicates that the control of the risk factors of NCDs is more effective when regulatory measures are established by the State, intervening on the environment, regulating marketing practices, availability, and provision of services, taxation of products harmful to health, food labeling, among others ²³23. World Health Organization (WHO). Best Buys and Other Recommended Interventions for the Prevention and Control of Noncommunicable Diseases Updated (2017). [acessado 2018 Ago 14]. Disponível em: http://who.int/ncds/management/WHO_Appendix_BestBuys.pdf
http://who.int/ncds/management/WHO_Appen... . Adopting regulatory measures recommended by the WHO, Brazil was considered an example in the world by curbing the prevalence of tobacco use ²⁴24. Giovino GA, Mirza SA, Samet JM, Gupta PC, Jarvis MJ, Bhala N, Peto R, Zatonski W, Hsia J, Morton J, Palipudi KM, Asma S; GATS Collaborative Group. Representative cross-sectional household surveys. Lancet 2012; 380(9842):668-679.^,2525. Malta DC, Reis AAC, Jaime PC, Morais Neto OL, Silva MMA, Akerman M. O SUS e a Política Nacional de Promoção da Saúde: perspectiva resultados, avanços e desafios em tempos de crise. Cien Saude Colet 2018; 23(6):1799-1809. . Among these measures, the ban on tobacco advertising stands out: ratification of the 2006 Framework Convention on Tobacco Control (FCTC); Law No. 12.546 of 2011; and the 2014 presidential decree that established smoke-free environments, increasing cigarette warning spaces and cigarette taxation, and setting the minimum price for marketing, among others ²⁵25. Malta DC, Reis AAC, Jaime PC, Morais Neto OL, Silva MMA, Akerman M. O SUS e a Política Nacional de Promoção da Saúde: perspectiva resultados, avanços e desafios em tempos de crise. Cien Saude Colet 2018; 23(6):1799-1809. . The stabilized prevalence of tobacco use identified here indicates that new measures must be implemented. For example, adopting generic packaging, enforcing smoke-free environments and making point-of-sale inspections, preventing illegal smuggling, and investing in supporting small-scale farmers in crop diversification, among other strategies ²³23. World Health Organization (WHO). Best Buys and Other Recommended Interventions for the Prevention and Control of Noncommunicable Diseases Updated (2017). [acessado 2018 Ago 14]. Disponível em: http://who.int/ncds/management/WHO_Appendix_BestBuys.pdf
http://who.int/ncds/management/WHO_Appen... .

In the case of alcohol, the country has made progress in implementing the Prohibition Act, which regulates the direction, as well as enforcement measures ²⁵25. Malta DC, Reis AAC, Jaime PC, Morais Neto OL, Silva MMA, Akerman M. O SUS e a Política Nacional de Promoção da Saúde: perspectiva resultados, avanços e desafios em tempos de crise. Cien Saude Colet 2018; 23(6):1799-1809. . However, new actions are still required, such as applying comprehensive prohibitions or restrictions on exposure to alcohol advertising (in the media), imposing restrictions on its marketing (reducing opening hours and sale outlets), adopting measures to restrict or prohibiting the promotion of beverages in “open bars” ²³23. World Health Organization (WHO). Best Buys and Other Recommended Interventions for the Prevention and Control of Noncommunicable Diseases Updated (2017). [acessado 2018 Ago 14]. Disponível em: http://who.int/ncds/management/WHO_Appendix_BestBuys.pdf
http://who.int/ncds/management/WHO_Appen... ; changing Law No. 9.294/1996, which considers restrictions on alcohol marketing only for beverages with an alcohol content above 13 degrees Gay-Lussac, to cover beers and “ice” drinks ²³23. World Health Organization (WHO). Best Buys and Other Recommended Interventions for the Prevention and Control of Noncommunicable Diseases Updated (2017). [acessado 2018 Ago 14]. Disponível em: http://who.int/ncds/management/WHO_Appendix_BestBuys.pdf
http://who.int/ncds/management/WHO_Appen... ^,2525. Malta DC, Reis AAC, Jaime PC, Morais Neto OL, Silva MMA, Akerman M. O SUS e a Política Nacional de Promoção da Saúde: perspectiva resultados, avanços e desafios em tempos de crise. Cien Saude Colet 2018; 23(6):1799-1809. .

Consumption of healthy foods, such as fruits and vegetables, is costly. As a consequence, fiscal incentive measures would be required to increase their use, as recommended in the NCD Coping Plan ⁶6. Malta DC, Morais Neto OL, Silva Júnior JB. Apresentação do plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis no Brasil, 2011 a 2022. Epidemiol Serv Saude 2013; 20(4):425-438. . Mexico adopted regulations on high-sugar and ultra-processed foods and beverages in 2013, which resulted in a 10% reduction of the consumption of soft drinks and 15% increase of water consumption ²⁶26. Organização Pan-Americana de Saúde (OPAS). Fatores de risco para doenças crônicas não transmissíveis nas Américas: Considerações sobre o fortalecimento da. capacidade regulatória . Washington; OPAS; 2016. Documento de Referência Técnica REGULA. .

There have been numerous advances in the area of food in the country, such as the preparation of the Food Guide for the Brazilian population (2014); encouraging breastfeeding; the National Fresh Food Acquisition Program, among others ²⁵25. Malta DC, Reis AAC, Jaime PC, Morais Neto OL, Silva MMA, Akerman M. O SUS e a Política Nacional de Promoção da Saúde: perspectiva resultados, avanços e desafios em tempos de crise. Cien Saude Colet 2018; 23(6):1799-1809.^,2727. Jaime P, Delmuè DCC, Campello T, Silva DO, Santos LMP. Um olhar sobre a agenda de alimentação e nutrição nos trinta anos do Sistema Único de Saúde. Cien Saude Colet 2018; 23(6):1829-1836. . Although some stability has been noted in recent years in the phenomenon of obesity in Brazilian capitals, the challenges to detain the growth of this problem are still huge, which requires effective regulatory measures, approval of legislation on taxation of ultra-processed foods, healthy food subsidies, and child food marketing ban ²⁵25. Malta DC, Reis AAC, Jaime PC, Morais Neto OL, Silva MMA, Akerman M. O SUS e a Política Nacional de Promoção da Saúde: perspectiva resultados, avanços e desafios em tempos de crise. Cien Saude Colet 2018; 23(6):1799-1809. . Measures such as taxation of sugary drinks are among the recommendations currently made by the WHO and have already been adopted in many countries ²³23. World Health Organization (WHO). Best Buys and Other Recommended Interventions for the Prevention and Control of Noncommunicable Diseases Updated (2017). [acessado 2018 Ago 14]. Disponível em: http://who.int/ncds/management/WHO_Appendix_BestBuys.pdf
http://who.int/ncds/management/WHO_Appen... ^,2626. Organização Pan-Americana de Saúde (OPAS). Fatores de risco para doenças crônicas não transmissíveis nas Américas: Considerações sobre o fortalecimento da. capacidade regulatória . Washington; OPAS; 2016. Documento de Referência Técnica REGULA. . One must be aware of bills that try to hamper the marketing of fruits and vegetables by small-sized farmers ²⁸28. Projeto limita orgânicos a agricultor familiar e descarta pequeno produtor... - Veja mais em. [acessado 2018 Ago 14]. Disponível em: https://economia.uol.com.br/noticias/redacao/2018/07/05/restricoes-venda-direta-produtos-organicos.htm
https://economia.uol.com.br/noticias/red... or the opposition of the national food industry to the implementation of labeling containing health-related warnings aimed at clarifying the consumer about the high levels of sugar, salt and fat in ultra-processed products ²⁹29. Colucci C. Brasil terá arrojo do Chile em rótulos de alimentos insalubres? [acessado 2018 Fev 13]. Disponível em: https://www1.folha.uol.com.br/colunas/claudiacollucci/2018/02/brasil-tera-arrojo-do-chile-em-rotulos-de-alimentos-insalubres.shtml?loggedpaywall
https://www1.folha.uol.com.br/colunas/cl... .

Studies point to the importance of physical activity incentive programs, such as the Health Academy, in increasing levels of PA ³⁰30. Pratt M, Brownson RC, Ramos LR, Malta DC, Hallal PC, Reis RS, Parra DC, Simões EJ. Project GUIA: A model for understanding and promoting physical activity in Brazil and Latin America. J Phys Act Health 2010; 7(Supl. 2):S131-S134.^,3131. Simões EJ, Hallal PC, Siqueira FV, Schmaltz C, Menor D, Malta DC, Duarte H, Hino AA, Mielke GI, Pratt M, Reis RS. Effectiveness of a scaled up physical activity intervention in Brazil: A natural experiment. Prev Med 2016; 103S:S66-S72. . When inserted in primary care, these programs promote improvements in physical space and articulate health promotion actions and are responsible for giving access to such practices to low-income and low-schooling populations, the elderly and women, precisely those with less access to PA ³¹31. Simões EJ, Hallal PC, Siqueira FV, Schmaltz C, Menor D, Malta DC, Duarte H, Hino AA, Mielke GI, Pratt M, Reis RS. Effectiveness of a scaled up physical activity intervention in Brazil: A natural experiment. Prev Med 2016; 103S:S66-S72.^,3232. Malta DC, Silva Júnior JB. Policies to promote physical activity in Brazil. Lancet [Internet]. 2012 Jul [cited 2014 Fev 12]; 380(9838):195-196. Available from: http://www.lancet.com/journals/lancet/article/PIIS0140-6736(12)61041-1/fulltext
http://www.lancet.com/journals/lancet/ar... . The reduced prevalence of PA in recent years should be monitored and can be explained by both the country’s economic crisis, which reduces access to these practices, and the smaller expansion of these programs in the SUS.

In the prevention and control of hypertension and diabetes, measures to promote health (reduction of salt, tobacco, alcohol), as well as primary health care and the adoption of self-care practices are effective. Brazil has made notable progress in expanding the Family Health Strategy and in the access to medicines for appropriate treatment, including free treatment for NCDs ⁶6. Malta DC, Morais Neto OL, Silva Júnior JB. Apresentação do plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis no Brasil, 2011 a 2022. Epidemiol Serv Saude 2013; 20(4):425-438.^,3333. World Obesity Federation. World Obesity Day [Internet]. 2017 [cited 2017 Oct 30]. Available from: http://www.obesityday.worldobesity.org/
http://www.obesityday.worldobesity.org/...

34. Rasella D, Harhay MO, Pamponet ML, Aquino R, Barreto ML. Impact of Primary Health Care on Mortality from Heart and Cerebrovascular Diseases in Brazil: a Nationwide Analysis of Longitudinal Data. BMJ 2014; 349:g4014.

35. Schmidt MI, Duncan BB, Azevedo e Silva G, Menezes AM, Monteiro CA, Barreto SM, Chor D, Menezes PR. Chronic non-communicable diseases in Brazil: burden and current challenges. Lancet 2011; 377(9781):1949-1961.^-3636. Souza MFN, Malta DC, França EB, Barreto ML. Transição da saúde e da doença no Brasil e nas Unidades Federadas durante os 30 anos do Sistema Único de Saúde. Cien Saude Colet 2018; 23(6):1737-1750. . Recent years have witnessed a substantial increase in the prevalence rate of diabetes in the population with low levels of education when compared to those who are 12 years and over. Besides being driven by obesity and aging, this problem can be understood in the context of unequal access to health services, promotion practices, and also in the increased poverty and economic crisis ¹⁰10. Schramm JM, Paes-Sousa R, Mendes LVP. Políticas de austeridade e seus impactos na saúde: um debate em tempos de crises . Rio de Janeiro: Fiocruz; 2018^,1414. Rasella D, Basu S, Hone T, Paes-Sousa R, Ocke´-Reis CO, Millett C. Child morbidity and mortality associated with alternative policy responses to the economic crisis in Brazil: A nationwide microsimulation study. PLoS Med 2018; 15(5):e1002570. .

Conclusion

The austerity measures currently implemented in Brazil could significantly affect the supply of SUS actions and services, contributing to the deterioration of people’s health. Worse results concerning NCDs and risk factors described here are associated with the context of economic crisis and austerity. The cuts promoted by EC95 are a profound blow to the SUS and social policies, resulting in increased poverty and extreme poverty ³⁷37. Relatórios Luz: síntese e completo de 2017. Grupo de Trabalho da Sociedade Civil para Agenda 2030 . [acessado 2017 Out 1]. Disponível em: https://gtagenda2030.org.br/
https://gtagenda2030.org.br/... . Moreover, if added to the results shown here on the generalized increase of a series of risk factors associated with the NCDs, explain the interrupted reduction in mortality in this group of diseases. The continuity of the previously mentioned restriction measure also suggests an inverted trend of the improvement of the indicators studied here.

Also noteworthy is the weakening regulatory role of the Brazilian government in the issue of protective measures. Moving forward in tackling NCDs involves policy decisions and the implementation of regulatory measures that address the interests of the food, alcohol, and tobacco industry ⁴4. World Health Organization (WHO). Global Action Plan for the Prevention and Control of NCDs 2013-2020 [Internet]. Geneva: World Health Organization; 2013. [cited 2014 Oct 29]. Available from: http://www.who.int/nmh/events/ncd_action_plan/en/
http://www.who.int/nmh/events/ncd_action... ^,2323. World Health Organization (WHO). Best Buys and Other Recommended Interventions for the Prevention and Control of Noncommunicable Diseases Updated (2017). [acessado 2018 Ago 14]. Disponível em: http://who.int/ncds/management/WHO_Appendix_BestBuys.pdf
http://who.int/ncds/management/WHO_Appen... ^,2626. Organização Pan-Americana de Saúde (OPAS). Fatores de risco para doenças crônicas não transmissíveis nas Américas: Considerações sobre o fortalecimento da. capacidade regulatória . Washington; OPAS; 2016. Documento de Referência Técnica REGULA. .

Performance in the NCDs goals should be continuously monitored by the country, civil society, education, and research institutions, as well as by the WHO and the United Nations, watchful regarding goals for the reductions undertaken at national and global levels, including the Sustainable Development 2030 Agenda ⁵5. United Nations. Agenda 2030 e nos Objetivos do Desenvolvimento Sustentável. ODS . [cited 2014 Oct 29]. Available from: http://www.agenda2030.org.br/
http://www.agenda2030.org.br/... .

Within its limits, this study observes tendencies and does not lend itself to the analysis of causes. Besides, the observation time is still short and sensitive to random swings. Therefore, the observation process must continue. In spite of these restrictions, in view of studies in other contexts, especially those that analyze the effects of austerity measures on health adopted in several European countries ⁹9. Parmar D, Stavropoulou C, Ioannidis JP. Health outcomes during the 2008 financial crisis in Europe: systematic literature review. BMJ 2016; 354:i4588.^,2222. Stuckler D, Basu S. A economia desumana: porque mata a austeridade . Lisboa: Editorial Bizâncio; 2014. , the findings described here, together with other accumulated evidence on these effects, become potential signposts that the goals and deadlines for the control of NCDs in the country can be severely affected by the measures contained in EC95 of 2016.

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