Abstract

The present study analyzed trends in premature mortality from Noncommunicable diseases (NCDs) between 1990 and 2019, the projections up to 2030, and the risk factors (RFs) attributable to these diseases in the Community of Portuguese Language Countries (CPLP). Estimates from the Global Burden of Disease (GBD) study and the analysis of the burden of premature mortality due to NCDs were used for nine CPLP countries, applying age-standardized rates, using RStudio. Portugal, Brazil, Equatorial Guinea, Angola, and Guinea Bissau showed declining premature mortality rates caused by NCDs, while East Timor, Cape Verde, São Tomé and Príncipe, and Mozambique showed an increase in rates. Projections indicate that none of the countries is expected to achieve the goals of reducing premature mortality due to NCDs by one third by 2030. The attributable burden of disease showed that the most important RFs in 2019 were: high systolic blood pressure (SBP), tobacco, dietary risks, high body mass index (BMI), and air pollution. It can therefore be concluded that there are profound differences in the burden of NCDs among the countries, with better results in Portugal and Brazil, and that no CPLP country is likely to reach the NCD reduction target by 2030.

Key words:
Noncommunicable diseases; Risk Factors; Global Burden of Disease; Community of Portuguese Language Countries; Sustainable Development Goals

Introduction

Noncommunicable diseases (NCDs) are one of the main global health problems, responsible for a large number of early deaths, disabilities, and a loss of quality of life¹1 World Health Organization. Global Action Plan for the Prevention and Control of NCDs 2013-2020 [internet]. Geneva: World Health Organization; 2013 [cited 2019 mai 20]. Available from: https://www.who.int/publications/i/item/9789241506236. NCDs also generate negative economic impacts on families, communities, and society²2 Abegunde DO, Mathers CD, Adam T, Ortegon M, Strong K. The burden and costs of chronic diseases in low-income and middle-income countries. Lancet 2007; 370(9603):1929-1938..

It is estimated that, annually, 41 million deaths around the world (71% of all deaths) are caused by NCDs, and of those deaths, 15 million are premature (30 to 69 years of age) and approximately 12 million occur in low- and middle-income countries³3 World Health Organization (WHO). Noncommunicable diseases [Internet]. 2018 [cited 2022 jul 5]. Available from: https://apps.who.int/iris/handle/10665/ 274512
https://apps.who.int/iris/handle/10665/ ... . The greatest probability of premature death occurs in African nations (22%), the Eastern Mediterranean (24%), and Southeast Asia (23%), followed by Europe (17%), the Western Pacific (16%), and the Americas (15%)⁴4 World Health Organization (WHO). Noncommunicable Diseases Country Profiles 2018 [Internet]. Geneva: WHO; 2018 [cited 2019 maio 20]. Available from: https://apps.who.int/iris/handle/10665/274512..

NCDs have a common set of determining socioeconomic factors and modifiable risk factors (RF) that result in the possibility of implementing a population intervention and public policy approach for prevention and control, together with measures aimed at social inclusion and the reduction of inequalities¹1 World Health Organization. Global Action Plan for the Prevention and Control of NCDs 2013-2020 [internet]. Geneva: World Health Organization; 2013 [cited 2019 mai 20]. Available from: https://www.who.int/publications/i/item/9789241506236^,55 World Health Organization (WHO). Best Buys and Other Recommended Interventions for the Prevention and Control of Noncommunicable Diseases [Internet]. Geneva: WHO; 2017 [cited 2019 maio 20]. Available from: https://apps.who.int/iris/bitstream/handle/ 10665/259232/WHO-NMH-NVI-17.9-eng.pdf..

To handle the problem, in 2011, the UN promoted a high-level meeting, examining the possibility of countries joining the discussions on the theme. This meeting resulted in the approval of the Global Plan for NCD by the World Health Organization (WHO)¹1 World Health Organization. Global Action Plan for the Prevention and Control of NCDs 2013-2020 [internet]. Geneva: World Health Organization; 2013 [cited 2019 mai 20]. Available from: https://www.who.int/publications/i/item/9789241506236 in 2013, and in 2015, NCDs were included in the 2030 Agenda for Sustainable Development, which establishes the goal of reducing mortality due to NCDs by one third⁶6 United Nations (UN). Transforming our world: the 2030 Agenda for Sustainable Development [Internet]. 2015 [cited 2021 dez 8]. Available from: https://sustainabledevelopment.un.org/post2015/transformingourworld.
https://sustainabledevelopment.un.org/po... .

However, the fiscal austerity measures and cuts in public spending on health implemented in several countries, especially due to the financial crisis in 2008 in Europe and Africa⁷7 Allen F, Giovannetti G. The effects of the financial crisis on Sub-Saharan Africa. Rev Dev Fin 2011; 1(1):1-27., as well as in Brazil after 2015/2016⁸8 Malta DC, Duncan BB, Barros MBA, Katikireddi SV, Souza FM, Silva AG, Machado DB, Barreto ML. Medidas de austeridade fiscal comprometem metas de controle de doenças não transmissíveis no Brasil. Cien Saude Colet 2018; 23(10):3115-3122., indicate a decline in child health, mental health, and an increase in NCDs⁹9 Zeltner T, Riahi F, Huber J. Acute and Chronic Health Challenges in Sub-Saharan Africa: An Unfinished Agenda. In: Groth H, May J, editors. Africa's Population: In Search of a Demographic Dividend. Edinburgh: Springer Cham; 2017. p. 283-297., which may hinder the achievement of the Sustainable Development Goals (SDG) established in the 2030 Agenda.

Therefore, it is important to monitor the burden of NCDs and their risk factors, as well as to achieve the SDGs, especially within partner countries, seeking food collaboration and reciprocal participation. The Community of Portuguese Language Countries (CPLC) have more than 500 years of history and cultural and linguistic identity in common, which unite and join the peoples of Angola, Cabo Verde, Guinea-Bissau, Equatorial Guinea, Mozambique, and Sao Tome and Principe, in Africa; Brazil, from South America; Portugal, from Europe; and East Timor, from Asia¹⁰10 Go´es JC, Antunes E. Os 20 anos da comunidade dos países de língua portuguesa na imprensa brasileira: discutindo as condições para uma communitas possível. Media Jornal 2016; 16(29):169-189.. Its Strategic Plan of Health Cooperation (SPHC) identifies the fight against NCDs as a priority for the cooperation among the member states¹¹11 Comunidade dos Países de Língua Portuguesa. Ficha Técnica: Plano de Atividades da GARD - CPLP de janeiro 2020 a dezembro 2023 [Internet]. 2020 [acessado 2022 jul 5]. Disponível em: http://gard-cplp.ihmt.unl.pt/Documentos/GARD/Plano-de-atividades-GARD-CPLP-20-23_9marco20.pdf.
http://gard-cplp.ihmt.unl.pt/Documentos/... .

There are still few studies regarding the performance of the CPLP in terms of the 2030 agenda; therefore, there is an important opportunity to make progress in such a diagnosis and contribute to the strengthening of partnerships, which can allow the group to monitor the progress in reaching the SDG. Authors, such as Milton Santos, defend the thesis according to which the process of globalization builds a “perverse world with a logic of profit, but which can be changed, by searching for a more humane world”¹²12 Santos M. Por uma outra globalizac¸a~o: do pensamento u´nico a` conscie^ncia universal. 2ª ed. Rio de Janeiro: Record; 2000., rescuing the “experience of living together and in solidarity”. Boaventura Sousa Santos also defends cultures and frontier identities as doors across which migration flows¹³13 Santos BS. Modernidade, identidade e a cultura de fronteira. Tempo Soc 1994; 5(1/2):31-52.. Hence, the CPLP would have the possibility of operating as a community in constant dialogue, seeking the exchange of harmonious experiences¹⁴14 Bauman Z. Comunidade: a busca por seguranc¸a no mundo. Rio de Janeiro: Jorge Zahar Editor; 2003.. Studies which cover different themes referring to the CPLP may support the cooperation between those countries.

This study, therefore, aims to analyze the tendencies for premature mortality due to NCDs between 1990 and 2019, the projections up to 2030, and the RF attributable to those diseases within the CPLP.

Methodology

The present study used data and estimates from the Global Burden of Diseases (GBD) study developed by the Institute of Health Metrics and Evaluation (IHME)¹⁵15 GBD 2019 Risk Factors Collaborators. Global burden of 87 risk factors in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet 2020; 396(10258):1223-1249.. The GBD makes estimates for general mortality and for specific causes, disabilities and risk factors, along with specific estimates by age and sex, since 1990, for 204 countries around the world (including selected subnational units), 21 regions, and 7 subregions, which allows for the estimation of the burden of diseases in each country¹⁵15 GBD 2019 Risk Factors Collaborators. Global burden of 87 risk factors in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet 2020; 396(10258):1223-1249..

Different data sources, in addition to published sources available in the countries, were used, totaling more than 300,000 available sources. However, the GBD applies methodologies for adjustment, standardization, and validation of the estimates. Mortality data is treated considering: 1) redistribution of garbage codes (GC) of causes which may be considered as basic causes or ill-defined causes of death; 2) correction for the deaths without notifications or underreporting¹⁶16 GBD 2017 Causes of Death Collaborators. Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018; 392(10159):1736-1788., besides the standardization of the rates, using standardized global population as estimated by the IHME¹⁷17 Vollset SE, Goren E, Yuan CW, Cao J, Smith AE, Hsiao T, Bisignano C, Azhar GS, Castro E, Chalek J, Dolgert AJ, Frank T, Fukutaki K, Hay SI, Lozano R, Mokdad AH, Nandakumar V, Pierce M, Pletcher M, Robalik T, Steuben KM, Wunrow HY, Zlavog BS, Murray CJL. Fertility, mortality, migration, and population scenarios for 195 countries and territories from 2017 to 2100: a forecasting analysis for the Global Burden of Disease Study. Lancet 2020; 396(10258):1285-1306.. Moreover, the data were adjusted by other national and international sources, allowing for the comparison between different populations over time¹⁷17 Vollset SE, Goren E, Yuan CW, Cao J, Smith AE, Hsiao T, Bisignano C, Azhar GS, Castro E, Chalek J, Dolgert AJ, Frank T, Fukutaki K, Hay SI, Lozano R, Mokdad AH, Nandakumar V, Pierce M, Pletcher M, Robalik T, Steuben KM, Wunrow HY, Zlavog BS, Murray CJL. Fertility, mortality, migration, and population scenarios for 195 countries and territories from 2017 to 2100: a forecasting analysis for the Global Burden of Disease Study. Lancet 2020; 396(10258):1285-1306.^,1818 GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018; 392(10159):1789-17858.. Further details about the GBD are available in earlier publications¹⁸18 GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018; 392(10159):1789-17858..

The current study analyzed the burden of premature deaths by NCDs for the 9 countries of the CPLP, using the definition adopted by the WHO¹1 World Health Organization. Global Action Plan for the Prevention and Control of NCDs 2013-2020 [internet]. Geneva: World Health Organization; 2013 [cited 2019 mai 20]. Available from: https://www.who.int/publications/i/item/9789241506236 and by the 2030 Agenda⁶6 United Nations (UN). Transforming our world: the 2030 Agenda for Sustainable Development [Internet]. 2015 [cited 2021 dez 8]. Available from: https://sustainabledevelopment.un.org/post2015/transformingourworld.
https://sustainabledevelopment.un.org/po... , which consider premature the deaths by NCDs occurring to people aged 30 to 69 years¹1 World Health Organization. Global Action Plan for the Prevention and Control of NCDs 2013-2020 [internet]. Geneva: World Health Organization; 2013 [cited 2019 mai 20]. Available from: https://www.who.int/publications/i/item/9789241506236^,66 United Nations (UN). Transforming our world: the 2030 Agenda for Sustainable Development [Internet]. 2015 [cited 2021 dez 8]. Available from: https://sustainabledevelopment.un.org/post2015/transformingourworld.
https://sustainabledevelopment.un.org/po... . We calculated the absolute number and the standardized rates of death, of years of life lost due to premature death and disability (DALY), years of life lost (YLL) due to premature death, and years lived with disabilities (YLD). The metrics were calculated for the total number of NCDs and stratified by: cardiovascular diseases (CVD) (I00-I99), chronic respiratory diseases (J30-J98), diabetes mellitus (E10-E14), and neoplasms (C00-C97), in 1990 and 2019, and considering the population between 30 and 69 years of age. Furthermore, the percentage of change between 1990 and 2019 was also verified.

Considering SDG target 3.4, which established a reduction, up to 2030, of one third of all premature deaths by NCDs, and indicator 3.4.1: “mortality rates attributed to cardiovascular diseases (CVD), cancer, diabetes, and chronic respiratory diseases”, projections up to 2030 were calculated, using the linear progression model. To calculate the projections for 2030, the same behavior was considered for the mortality rates found in each country, from 2015 to 2019, based on the initial moment of the goals agreed upon by the United Nations in 2015⁶6 United Nations (UN). Transforming our world: the 2030 Agenda for Sustainable Development [Internet]. 2015 [cited 2021 dez 8]. Available from: https://sustainabledevelopment.un.org/post2015/transformingourworld.
https://sustainabledevelopment.un.org/po... .

This study also estimated that the burden of NCDs attributable to the RF and to the changes that took place between 1990 and 2019 in its distribution. A ranking of the RF was created to represent the changes for each CPLP country.

To calculate the burden of NCDs attributable to the RF, the GBD uses a hierarchical list of RF, which is analyzed in four levels. Level 1 stratifies the RF in three groups: metabolic, behavioral, and environmental. Level 2 details the RF in level 1, including 20 RFs. Levels 3 and 4 progress into detailing, and in 2019, the GBD study analyzed 87 RFs¹⁵15 GBD 2019 Risk Factors Collaborators. Global burden of 87 risk factors in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet 2020; 396(10258):1223-1249.. The current study analyzed hierarchical levels 1 and 2 related to NCDs, as shown in Figure 3.

To calculate the value attributable to RF, the GBD follows the established framework for comparative risk assessment (CRA), which comprises 5 main steps: 1) Estimate the level of exposure by means of the sources available in the countries by using a search and identification of data related to each risk factor; 2) Estimate the pairs of RFs and their outcomes; 3) Estimate the relative risks in terms of exposure; 4) Estimate the Theoretical Minimum Risk Exposure Level (TMREL), defined as the minimum level of exposure to each RF, in which the probability of occurrence of a given event is the least possible. The TMREL is used to calculate the population attributable factor (PAF) for different causes of death, diseases, or disabilities; 5) The calculation of the PAF, defined as the proportion of the number of cases that may be attributed to an independent exposure¹⁵15 GBD 2019 Risk Factors Collaborators. Global burden of 87 risk factors in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet 2020; 396(10258):1223-1249..

The TMRELs of the RFs evaluated in this study are: 1) systolic blood pressure (SBP): 110 to 115 mm Hg; 2) fasting glycemia: 85 to 99 mg/dL; 3) LDL cholesterol: between 27 and 50 mg/dL; 4) body mass index (BMI): 20 to 25 kg/m² for adults; 5) kidney function: albumin-creatinine ratio at <30 mg/g or rate of glomerular filtration >60 mL/min by 173 m²; 6) environmental air pollution: 2.4 to 5.9 μg/m³; 7) smoking: no exposure, including passive smoking; 8) dietary risks, consumption of 1 to 5 g of salt and 20 to 400 g of fruits and vegetables daily, among others; 9) physical activity: 8000 METs per day; 10) alcohol consumption: no consumption; 11) ideal temperature: 25.6 ºC; 12) drug use - no use; 13) safe sex - use of condoms; 14) occupational risks - no risk. Further information can be found in the GBD 2019 Risk Factors Collaborators¹⁵15 GBD 2019 Risk Factors Collaborators. Global burden of 87 risk factors in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet 2020; 396(10258):1223-1249..

In the comparisons between countries, we considered rates standardized by age. The analysis was conducted using R software, (RStudio Team, 2019), and the images were produced using the ggplot package.

The data from the GBD study is public and is available at http://ghdx.healthdata.org/. The GBD Brazil project was approved by the Research Ethics Committee from the Universidade Federal de Minas Gerais (UFMG), logged under project number CAAE - 62803316.7.0000.5149.

Results

Table 1 shows the number of deaths, mortality rates, and DALYs, as well as YLL, and YLD rates for all causes of death and those due to NCDs and the variation between 1990 and 2019. In Angola, the absolute number of deaths by all causes increased 94.6% and due to NCDs, increased 111.1%, meanwhile the rates of mortality by NCDs, DALY rates and YLL rates fell by 27.4%, 25.3%, and 28.1%, respectively; the YLD rate increased 7.8%. In Brazil, the deaths by NCDs in absolute numbers increased in 49.6%, reaching 337,098 deaths in 2019. However, the mortality rates standardized by NCDs indicate a decline (-39.3%) during the period. There was also a decline in the DALY (-36.7%), YLL (-39.8%), and YLD (-2.2%) rates. In Cape Verde, there was an increase in the absolute number of deaths by NCDs (143.4%), in mortality rates (7.6%), in DALY rates (4.2%), in YLL rates (1.9%), and in YLD rates (22.6%). Equatorial Guinea and Guinea-Bissau showed increases in the absolute number of deaths by NCDs (30.5 and 59.4%, respectively) and in the YLD rates (11.0 and 11.4%, respectively); however. the mortality rates (-47.0 and -15.0%, respectively, the DALY rates (-44.1 and -13.4%, respectively), and the YLL rates (-48.1 and -15.1%, respectively) showed a decline. Portugal presented a fall in the absolute number of deaths by NCDs (-25.9%), mortality rates (-43.5%), DALY rates (37.2%), and YLL rates (-43.0%); the YLD rate remained stable. In Mozambique, Sao Tome and Principe, and East Timor, an increase was observed in all of the analyzed metrics.

Table 2 shows the mortality rates standardized according to the four main NCDs for the CPLP for 1990 and 2019. In every country, there was a decline in the mortality rates by CVD and respiratory diseases, except for Sao Tome and Principe (5.5%), Mozambique (15.2%), and East Timor (19.9%), which showed increases for CVD. For CVD, the most significant declines were observed in Portugal (-66.3%) and Equatorial Guinea (-60.2%). For diabetes and neoplasms, the standards varied according to country, with some showing an increase and others, a decrease. For diabetes mellitus, there was a greater decline in Portugal (-54.9%) and an increase in Cape Verde, Guinea-Bissau, Mozambique, and Sao Tome and Principe (158.4; 4.7; 31.4 and 24.1%, respectively). Mortality by neoplasms showed a greater decline in Portugal (-19.7%) and Brazil (-17.9%) and a greater increase in Cape Verde (37%) and Mozambique (30.3%) (Table 2, Figure 1).

Figure 2 shows the temporal tendencies of premature mortality by NCDs (30 to 69 years of age) between 1990 and 2015 (solid red line), in each country, and the projections according to the SDGs proposed in UN 2030 Agenda, showing a one third reduction in mortality rates from 2015 onward (dotted green line). It also shows the linear projections based on what was observed between 2015 and 2019 in each country (dashed orange line). We can notice that none of the analyzed counties is likely to meet the reduction of one third in mortality due to NCDs as compared to 2015 levels. However, the worst performances are expected from Cape Verde, Sao Tome and Principe, and East Timor.

Figure 3 shows the rate of premature mortality by NCDs attributed to the risk factors in 1990 and 2019 for each CPLP country. In Angola, high SBP was the main RF in 1990 and 2019, with a reduction in the period, and it was responsible for 162.4 deaths/100,000 inhabitants due to CVD in 2019.

In Brazil, the main RF that contributed to mortality rates in 1990 were smoking (204.3/100,000 inhabitants), high SBP (180.0/100,00 inhabitants), dietary risks (138.4/100,000 inhabitants), and high BMI (108.9/100,000 inhabitants). In 2019, the mortality rates attributed to the RFs showed a decrease, and the high SBP moved to first place, contributing to 86.2 deaths/100,000 inhabitants by CVD, followed by smoking (81.8 deaths/100,000 inhabitants) and BMI (79.8 deaths/100,000 inhabitants).

In Cape Verde, in 1990, high SBP was the main RF and corresponded to 108.8 deaths/100,000 inhabitants by CVD. The second and third causes were air pollution (57.8 deaths/100,000 inhabitants by CVD and 15.5 deaths/100.000 inhabitants by respiratory diseases) and dietary risks (63.4 deaths/100,000 inhabitants by CVD and 7.9 deaths/100,000 inhabitants by neoplasms). In 2019, the mortality rates due to RFs increased, high SBP continued to be ranked first and high BMI, second. High SBP contributed to 114.0 deaths/100,000 inhabitants due to CVD. High BMI was responsible for 58.0, 15.3, and 12.6 deaths/100,000 inhabitants due to CVD, diabetes, and neoplasms, respectively.

In Equatorial Guinea, in 1990, high SBP, the main RF, was responsible for 273.6 deaths by CVD, while air pollution contributed to 155.1 deaths by CVD and 33.8 by respiratory diseases/100,000 inhabitants. In 2019, there was an important reduction in deaths due to RFs; high SBP continued to be ranked first, and was responsible for nearly 117.3 deaths due to CVDs, while BMI ranked second (66.8 by CVD and 32.0 by diabetes mellitus).

In Guinea-Bissau, high SBP, air pollution, and dietary risks were, in this order, the three main RFs attributed to premature deaths by NCDs in 1990 and 2019. The mortality rates attributed to CVD and high SBP were 235.4/100,000 inhabitants and 224.1/100,000 inhabitants in 1990 and 2019, respectively. Air pollution was responsible for 129.7 deaths by 100,000 inhabitants due to CVD and 19.5 by respiratory diseases in 2019.

In Mozambique, high SBP, air pollution and dietary risks were also the three main RF attributed to premature mortality by NCD in 1990 and 2019, and an increase can be observed in mortality rates due to the risk factors in 2019. High SBP was responsible for 187.2 deaths/100,000 inhabitants in 1990 and rose to 222.2 deaths/100,000 inhabitants in 2019. Air pollution contributed with 108.5 deaths/100,000 inhabitants due to CVD, 2.8 deaths/100,000 inhabitants by neoplasms, and 15.4 deaths by respiratory diseases in 1990; in 2019, the mortality rate was 117.0/100,000 inhabitants due to CVD, 3.8/100,000 inhabitants for neoplasms, and 13.1/100,000 inhabitants for respiratory diseases in 2019.

In Portugal, smoking, high SBP and high BMI were the main RFs in both 1990 and in 2019. An important reduction in mortality rates due to RFs was also observed in 2019. For example, the mortality rates by neoplasms attributed to smoking was 48.1/100,000 inhabitants and 40.4/100,000 inhabitants in 1990 and 2019, respectively.

In Sao Tome and Principe, high SBP was the main RF observed in the two evaluated periods, with 135.4 and 154.7 deaths/100,000 inhabitants in 1990 and 2019, respectively. Air pollution, the second RF in 1990 and third in 2019 totalled 68.9/100,000 inhabitants due to CVD and 15.9/100,000 inhabitants due to respiratory diseases in 2019.

In East Timor, an increase was found in the number of deaths due to RFs between 1990 and 2019. The high SBP was the main RF for both years and accounted for 152.3 deaths/100,000 inhabitants due to CVD in 1990, and 188.9 deaths/100,000 inhabitants due to CVD in 2019. Dietary risks contributed with 112.2 deaths/100,000 inhabitants due to CVD, 7.5 deaths/100,000 inhabitants by neoplasms in 1990, and 127.4 deaths/100,000 inhabitants due to CVD and 8.9 deaths/100,000 inhabitants due to neoplasms in 2019.

Discussion

The present study shows that there are profound differences in the NCD burden in the countries and great disparities among them. Some countries show declining mortality rates, such as Brazil and Portugal, which present better performances, followed by such countries as Equatorial Guinea, Angola, and Guinea-Bissau, with high rates, but showing decline. The more concerning scenarios are in countries like East Timor, Cape Verde, Sao Tome and Principe, and Mozambique, in which the mortality rates due to NCDs have shown an increase. The tendency analysis indicates that none of the nine Portuguese speaking countries is likely to meet the goals of a one-third reduction in premature mortality due to NCD by 2030. The burden of diseases attributable to RFs also shows differences between the countries. Cape Verde, Mozambique, Sao Tome and Principe, and East Timor have witnessed increases in the burden of disease due to RFs. In the remaining countries, the risks attributed to deaths by NCDs have been declining. The most important RFs in 2019 were high SBP, ranked first in the majority of the countries; smoking, dietary risks; high BMI; and air pollution (Mozambique and Guinea-Bissau, ranked second).

The inequalities in the NCD burden among the countries from the CPLP observed in the present study were also noticed in previous publications¹⁹19 Nascimento BR, Brant LCC, Oliveira GMM, Malachias MVB, Reis GMA, Teixeira RA, Malta DC, França E, Souza MFM, Roth GA, Ribeiro ALP. Epidemiologia das Doenças Cardiovasculares em Países de Língua Portuguesa: Dados do "Global Burden of Disease", 1990 a 2016. Arq Bras Cardiol 2018; 110(6):500-511.. The African continent shows enormous challenges, caused by their internal structure, huge inequalities, a lack of health service structure, among others⁶6 United Nations (UN). Transforming our world: the 2030 Agenda for Sustainable Development [Internet]. 2015 [cited 2021 dez 8]. Available from: https://sustainabledevelopment.un.org/post2015/transformingourworld.
https://sustainabledevelopment.un.org/po... ^,2020 Fasan O. Africa must industrialise and trade more to achieve the #SDGs [Internet]. The London School of Economics and Political Science Blog; 2015 [cited 2019 maio 22]. Available from: https://blogs.lse.ac.uk/africaatlse/2015/10/22/africa-must-industrialise-and-trade-more-to-achieve-the-sdgs/.
https://blogs.lse.ac.uk/africaatlse/2015... . The 2030 Agenda highlights the principle of shared responsibility, and the challenges in moving forward and not leaving anyone behind⁶6 United Nations (UN). Transforming our world: the 2030 Agenda for Sustainable Development [Internet]. 2015 [cited 2021 dez 8]. Available from: https://sustainabledevelopment.un.org/post2015/transformingourworld.
https://sustainabledevelopment.un.org/po... . However, the present study indicates that the perspectives are challenging, and without support from more developed countries and from the WHO, it is unlikely that there will be progress resulting in changes in the indicators⁶6 United Nations (UN). Transforming our world: the 2030 Agenda for Sustainable Development [Internet]. 2015 [cited 2021 dez 8]. Available from: https://sustainabledevelopment.un.org/post2015/transformingourworld.
https://sustainabledevelopment.un.org/po... ^,2020 Fasan O. Africa must industrialise and trade more to achieve the #SDGs [Internet]. The London School of Economics and Political Science Blog; 2015 [cited 2019 maio 22]. Available from: https://blogs.lse.ac.uk/africaatlse/2015/10/22/africa-must-industrialise-and-trade-more-to-achieve-the-sdgs/.
https://blogs.lse.ac.uk/africaatlse/2015... . Therefore, the SDGs may be able to influence national agendas to support the priorities of the global commitments established to achieve the SDG goals in terms of NCDs⁶6 United Nations (UN). Transforming our world: the 2030 Agenda for Sustainable Development [Internet]. 2015 [cited 2021 dez 8]. Available from: https://sustainabledevelopment.un.org/post2015/transformingourworld.
https://sustainabledevelopment.un.org/po... .

Despite the differences in the processes of sociohistorical and cultural development, the CPLP countries maintain the Portuguese language as a key link, together with the constitution of a lusophone community interested in developing connections, fraternity, and international cooperation in different areas, such as health, education, and economy. Bringing this network together in the sense of amplifying dialogue and articulation for collaborative actions to fight the challenges that prevent the achievement of the 2030 Agenda may be a strategic political action towards improvement. The most adequate instrument for that is the PECS. Hence, the results of this study should be incorporated into the implementation of the strategic priorities concerning NCDs.

This study presents a common challenge for the CPLP, which are the indicators referring to NCDs and the RFs. These results are aligned with the findings of the STEPS inquiries conducted in Cape Verde²¹21 World Health Organization (WHO). NCD Microdata Repository. Steps 2007: Cabo Verde, 2007 [Internet]. 2020 [cited 2022 jul 5]. Available from: https://extranet.who.int/ncdsmicrodata/index.php/catalog/319/related-materials.
https://extranet.who.int/ncdsmicrodata/i... , Mozambique²²22 World Health Organization (WHO). NCD Microdata Repository. Steps 2005: Mozambique, 2005 [Internet]. 2019 [cited 2022 jul 5]. Available from: https://extranet.who.int/ncdsmicrodata/index.php/catalog/726/related-materials.
https://extranet.who.int/ncdsmicrodata/i... , Sao Tome and Principe²³23 World Health Organization (WHO). NCD Microdata Repository. Steps 2008: Sao Tome and Principe, 2008 [Internet]. 2020 [cited 2022 jul 5]. Available from: https://extranet.who.int/ncdsmicrodata/index.php/catalog/735/related-materials.
https://extranet.who.int/ncdsmicrodata/i... , and East Timor²⁴24 World Health Organization (WHO). Fact Sheet: STEPS Survey Timor-Leste 2014 [Internet]. 2016 [cited 2022 jul 5]. Available from: https://apps.who.int/iris/handle/10665/204496.
https://apps.who.int/iris/handle/10665/2... . The National Health Inquiry with Physical Exam 2013-2016 in Portugal also corroborates the findings of our study²⁵25 Romana GQ, Kislaya I, Salvador MR, Gonçalves SC, Nunes B, Dias C. Multimorbilidade em Portugal: Dados do Primeiro Inquérito Nacional de Saúde com Exame Físico. Acta Med Port 2019; 32(1):30-37.. The objective of the GARD-CPLP (Global Alliance against Chronic Respiratory Diseases) was to contribute to a world in which every person is able to breathe freely²⁶26 Conceição C, Viveiros M, Cruz D, Pinto JR. 4º Congresso Nacional de Medicina Tropical - Seminário pré-congresso: Doenças respiratórias crónicas e tuberculose. In: Anais do Instituto de Higiene e Medicina Tropical [Internet]. 2017 [cited 2022 jul 5]. Disponível em: https://anaisihmt.com/index.php/ihmt/article/view/23.
https://anaisihmt.com/index.php/ihmt/art... ^,2727 Bousquet J, Mohammad Y, Bedbrook A, To T, McGihon R, Bárbara C, Melo-Gomes E, Rosado-Pinto J, Simão P, George F, Punturieri A, Kiley JP, Nunes E, Cossa A, Camargos P, Stelmach R, Cruz AA, Rostan MV, Yañez A, González-Díaz SN, Urrutia-Pereira M, Calderon MA, Gómez RM, German Z, Kolek V, Špičák V, Lan LTT, Hurd S, Lenfant C, Yorgancioglu A, Gemicioğlu B, Ekinci B, Ozkan Z, Abou Al-Zahab B, Dmeirieh A, Shifa R, Faroun H, AlJaber A, Halloum R, Fatmeh Y, Alzein A, Aloush J, Dib G, Shaaban R, Arrais M, Teixeira MC, Conceição C, Ferrinho P. Country activities of Global Alliance against Chronic Respiratory Diseases (GARD): Focus presentations at the 11th GARD General Meeting, Brussels. J Thorac Dis 2018; 10(12):7064-7072.. Such progress requires cooperative prevention and intersectoral actions, prioritizing public policies and investments¹1 World Health Organization. Global Action Plan for the Prevention and Control of NCDs 2013-2020 [internet]. Geneva: World Health Organization; 2013 [cited 2019 mai 20]. Available from: https://www.who.int/publications/i/item/9789241506236. There is the need for articulated, cooperative work, since no country should be left behind up to 2030⁶6 United Nations (UN). Transforming our world: the 2030 Agenda for Sustainable Development [Internet]. 2015 [cited 2021 dez 8]. Available from: https://sustainabledevelopment.un.org/post2015/transformingourworld.
https://sustainabledevelopment.un.org/po... .

A set of behavioral and metabolic RFs are the leading risks attributable to premature deaths caused by NCDs, such as smoking, dietary risks, high SBP, and high BMI. In three of the countries, air pollution is also an issue. Evidence indicates that the control of RFs for NCDs is more effective when regulatory measures are implemented by the state and the environment is changed by regulating trade, availability, and the providing of services⁶6 United Nations (UN). Transforming our world: the 2030 Agenda for Sustainable Development [Internet]. 2015 [cited 2021 dez 8]. Available from: https://sustainabledevelopment.un.org/post2015/transformingourworld.
https://sustainabledevelopment.un.org/po... ^,2828 Desidera´ Neto WA. A cooperac¸a~o internacional para o desenvolvimento como uma expressa~o especi´fica da cooperac¸a~o internacional: um levantamento teo´rico. Oikos 2014; 13(2):115-128.. The best evidence would include taxing products that are harmful to people’s health, labelling foods, regulating the commerce of alcohol and tobacco⁵5 World Health Organization (WHO). Best Buys and Other Recommended Interventions for the Prevention and Control of Noncommunicable Diseases [Internet]. Geneva: WHO; 2017 [cited 2019 maio 20]. Available from: https://apps.who.int/iris/bitstream/handle/ 10665/259232/WHO-NMH-NVI-17.9-eng.pdf.^,2929 Organização Pan-Americana de Saúde (OPAS). Fatores de risco para doenças crônicas não transmissíveis nas Américas: Considerações sobre o fortalecimento da Capacidade regulatória. Washington D.C.: OPAS; 2016., governmental measures establishing limits for the amount of salt used by food manufacturers, among other examples²⁹29 Organização Pan-Americana de Saúde (OPAS). Fatores de risco para doenças crônicas não transmissíveis nas Américas: Considerações sobre o fortalecimento da Capacidade regulatória. Washington D.C.: OPAS; 2016.. Therefore, it is urgent that measures of effective protection and public policies be taken by all countries.

It is important to highlight the important reduction in smoking as an RF for NCDs in most of the countries during the studied period. Countless regulatory measures have been adopted in the countries, including the prohibition of tobacco advertising, the ratification of the Convention-Picture on the use of Tobacco, decrees making environments smoking free, among other measures³⁰30 Malta DC, Silva MMA, Moura L, Morais Neto OL. A implantação do Sistema de Vigilância de Doenças Crônicas Não Transmissíveis no Brasil, 2003 a 2015: alcances e desafios. Rev Bras Epidemiol 2017; 20(4):661-675.. In Portugal, for instance, smoking continues to be the main RF, although it proved to be in decline during the period of our study.

High SBP was the first RF in most of the African countries and in East Timor, indicating the need to improve medical care and treatments, followed by primary health care, access to essential care, as well as progress in terms of prevention, reducing salt in foods, and creating regulatory measures, especially increasing taxes on ultra-processed foods¹1 World Health Organization. Global Action Plan for the Prevention and Control of NCDs 2013-2020 [internet]. Geneva: World Health Organization; 2013 [cited 2019 mai 20]. Available from: https://www.who.int/publications/i/item/9789241506236.

We should also highlight the importance of dietary risks and obesity, along with the need to make progress in such measures as the taxation of sugary drinks and ultra-processed foods, which are currently recommended by the WHO and that have already been adopted by some countries, such as Mexico, which reduced the consumption of fizzy drinks by 10%⁵5 World Health Organization (WHO). Best Buys and Other Recommended Interventions for the Prevention and Control of Noncommunicable Diseases [Internet]. Geneva: WHO; 2017 [cited 2019 maio 20]. Available from: https://apps.who.int/iris/bitstream/handle/ 10665/259232/WHO-NMH-NVI-17.9-eng.pdf.^,2929 Organização Pan-Americana de Saúde (OPAS). Fatores de risco para doenças crônicas não transmissíveis nas Américas: Considerações sobre o fortalecimento da Capacidade regulatória. Washington D.C.: OPAS; 2016.. However, the fight against this problem demands political will in order to go against the interests of the food industry²⁹29 Organização Pan-Americana de Saúde (OPAS). Fatores de risco para doenças crônicas não transmissíveis nas Américas: Considerações sobre o fortalecimento da Capacidade regulatória. Washington D.C.: OPAS; 2016..

Another RF that deserves attention is air pollution, which significantly affects health, causing a large number of premature deaths and hospitalizations. Some studies show associations between air pollution and CVD³¹31 World Health Organization (WHO). Review of evidence on health aspects of air pollution-REVIHAAP project: technical report. Copenhagen: WHO; 2013., diabetes³²32 Thiering E, Heinrich J. Epidemiology of air pollution and diabetes. Trends Endocrinol Metab 2015; 26(7):384-394., rheumatic diseases³³33 Sun G, Hazlewood G, Bernatsky S, Kaplan GG, Eksteen B, Barnabe C. Association between air pollution and the development of rheumatic disease: a systematic review. Int J Rheumatol 2016; 2016:5356307., cognitive function³⁴34 Clifford A, Lang L, Chen R, Anstey KJ, Seaton A. Exposure to air pollution and cognitive functioning across the life course - a systematic literature review. Environ Res 2016; 147:383-398., neurodegenerative diseases³⁵35 Xu X, Ha SU, Basnet R. A review of epidemiological research on adverse neurological effects of exposure to ambient air pollution. Front Public Health 2016; 4:157., and chronic respiratory diseases such as ashtma³3 World Health Organization (WHO). Noncommunicable diseases [Internet]. 2018 [cited 2022 jul 5]. Available from: https://apps.who.int/iris/handle/10665/ 274512
https://apps.who.int/iris/handle/10665/ ... . Therefore, there is a need to advance in intersectoral and structuring measures to control air pollution related to the development of public policies and the elaboration of norms regulating the issue and guiding interventions³⁶36 Nugent R, Bertram MY, Jan S, Niessen LW, Sassi F, Jamison DT, Pier EG, Beaglehole R. Investing in non-communicable disease prevention and management to advance the Sustainable Development Goals. Lancet 2018; 391(10134):2029-2035..

This study has some limitations which should also be mentioned. Our data analysis used the age group of 30 and 69 years to estimate premature death, according to that established by the WHO and adopted for the 2030 Agenda¹1 World Health Organization. Global Action Plan for the Prevention and Control of NCDs 2013-2020 [internet]. Geneva: World Health Organization; 2013 [cited 2019 mai 20]. Available from: https://www.who.int/publications/i/item/9789241506236^,66 United Nations (UN). Transforming our world: the 2030 Agenda for Sustainable Development [Internet]. 2015 [cited 2021 dez 8]. Available from: https://sustainabledevelopment.un.org/post2015/transformingourworld.
https://sustainabledevelopment.un.org/po... . However, it is important to remember that in some of the countries, such an age group could be different, due to the heterogeneity observed among the countries regarding low life expectation³⁷37 Nunes AB, Oliveira AP, Jamanca A, Brito DV, Silva NM, Duarte S, Coelho A. Asthma Management and Control in Portuguese Speaking Countries. Acta Med Port 2020; 33(4):269-274., considering the significant inequalities in epidemiological transition experienced by each country. In terms of RFs, the GBD assumes that the relative risks are distributed evenly in all the countries for some age groups and genders, thus requiring more caution in interpreting the data. The most distal RFs, such as the social health determinants, were not evaluated by the GBD; it is well-known that these may have a prevalence in intermediate RFs, even before affecting the attributable mortality estimates. Although the GBD methodology does adjust the different definitions of RF for a standardized definition, the adjustments may be insufficient, causing bias. Finally, it is important to highlight the difficulty for the GBD to obtain local information and access data from every country. The 2015-2019 period was used as a hypothetical scenario for projections, assuming that the same conditions will remain for the mortality rates in the years to come, which may not correspond to reality.

The GBD offers a unique and opportune platform to monitor the NCD burden, with the SDG related to health and all the geographic and demographic dimensions, as well as the RFs attributed to diseases, thus contributing to comparisons among the countries. However, it is important to improve the collection and analysis of non-aggregated data, supporting health planning, guiding the definition of priority interventions, which may boost the progress of the SDGs³⁸38 GBD 2015 SDG Collaborators. Measuring the health-related Sustainable Development Goals in 188 countries: a baseline analysis from the Global Burden of Disease Study 2015. Lancet 2016; 388(10053):1813-1850.. The GBD calculates the indicators for each country, using data available for each location. However, when systems of information and local data are not available, subregional and regional data is adopted for local estimations. Therefore, improvements in the data collection systems of these countries will certainly contribute to improve the estimates.

Conclusion

There are profound differences in the NCD burden in the member countries of the CPLP. Moreover, none of these countries is likely to reach the goal of reducing deaths by one third before 2030. Among the countries in the study, Portugal and Brazil present the best performances, whereas Angola, Guinea-Bissau, Mozambique, and Equatorial Guinea present the worse numbers. In terms of RFs, high SBP was a problem in most of the CPLP countries in 2019. To make truly effective progress, it is urgent that partnerships and exchanges be established among the CPLP countries, especially with the support of the countries which, to date, have the best indicators.

References

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