ABSTRACT:

Objective:

To describe the major noncommunicable diseases (NCDs) in Brazil, according to the information collected from individuals aged 18 years or older.

Methods:

Data from the National Health Survey (PNS), 2013, a transversal population-based study, were used. The proportions of each NCD were calculated and presented according to sex, with a 95% confidence interval (95%CI), with the absolute values.

Results:

Of the total respondents, 45.1% reported presenting at least one NCD. The region with the highest prevalence of NCDs was the South (52.1%). Hypertension showed the highest prevalence among NCDs, with 21.4%, followed by chronic back problem (18.5%), depression (7.6%), arthritis (6.4%), and diabetes (6.2%). The intense/very intense degree of limitation showed a higher prevalence of other mental illnesses (37.6%) and cerebrovascular accident (25.5%).

Conclusion:

The improvement of health services is essential for an effective response to the double burden of illness in the middle- and low-income countries.

Keywords:
Health surveys; Chronic disease; Hypertension; Diabetes mellitus; Low back pain; Epidemiological surveillance.

INTRODUCTION

Chronic noncommunicable diseases (NCDs), currently, are a major public health problem and have generated large numbers of premature deaths, loss in quality of life (with a high degree of limitation and disability in activities of daily living) and economic impacts for families, communities, and society at large¹1. Brasil. Ministério da Saúde. Plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis (DCNT) no Brasil, 2011-2022. Brasília: Ministério da Saúde; 2011. ²2. World Health Organization. Global status report on noncommunicable diseases 2010. Geneva: WHO; 2011..

Each year, NCDs account for 36 million (63%) deaths, with an emphasis on cardiovascular diseases, diabetes, cancer, and chronic respiratory disease. About 80% of deaths from NCDs occur in low- or middle-income countries, where 29% are people aged younger than 60 years, while in high-income countries, only 13% are early deaths¹1. Brasil. Ministério da Saúde. Plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis (DCNT) no Brasil, 2011-2022. Brasília: Ministério da Saúde; 2011. ²2. World Health Organization. Global status report on noncommunicable diseases 2010. Geneva: WHO; 2011..

In Brazil, NCDs also constitute a health problem in a large magnitude and account for 72% of causes of death, especially cardiovascular diseases (31.3%), cancer (16.3%), diabetes (5.2%), and chronic respiratory disease (5.8%). NCDs affect individuals of all socioeconomic strata and, more intensely, those belonging to vulnerable groups such as the elderly people and those with a low education level and income³3. Duncan BB, Stevens A, Iser BPM, Malta DC, Silva GA, Moura L, et al. Mortalidade por Doenças Crônicas no Brasil: situação em 2009 e tendências de 1991 a 2009. Saúde Brasil. 2010. Uma análise da situação de saúde.; Brasília: Ministério da Saúde 2011. ⁴4. Malta DC, Merhy EE. The path of the line of care from the perspective of nontransmissible chronic diseases. Interface - Comunic Saúde Educ 2010; 14(34): 593-605..

NCDs are characterized by multiple causative factors, many risk factors, long latency periods, prolonged course, and noninfectious origin and associate themselves with functional limitations and disabilities. Their occurrence is strongly influenced by living conditions, by social inequalities, not only being a result of lifestyles. NCDs still require a systematic approach to treatment, requiring new strategies from health services⁴4. Malta DC, Merhy EE. The path of the line of care from the perspective of nontransmissible chronic diseases. Interface - Comunic Saúde Educ 2010; 14(34): 593-605. ⁵5. World Health Organization. Preventing chronic diseases: a vital investment.; Geneva: WHO 2005..

The World Health Organization (WHO) includes the diseases of the circulatory system (cerebrovascular and cardiovascular), neoplasms, chronic respiratory diseases, and diabetes mellitus as NCDs. These diseases have a set of risk factors in common, resulting in the possibility of presenting a common approach to prevention²2. World Health Organization. Global status report on noncommunicable diseases 2010. Geneva: WHO; 2011. ⁴4. Malta DC, Merhy EE. The path of the line of care from the perspective of nontransmissible chronic diseases. Interface - Comunic Saúde Educ 2010; 14(34): 593-605. ⁵5. World Health Organization. Preventing chronic diseases: a vital investment.; Geneva: WHO 2005..

Other chronic conditions contribute greatly to the increased burden of disease, such as mental and neurological, bone and joint disorders, autoimmune diseases, among others⁵5. World Health Organization. Preventing chronic diseases: a vital investment.; Geneva: WHO 2005.. However, these chronic conditions differ from the NCDs group named by WHO, because they generally do not share the same risk factors, requiring different intervention strategies and public policy efforts, as in the case of mental disorders⁴4. Malta DC, Merhy EE. The path of the line of care from the perspective of nontransmissible chronic diseases. Interface - Comunic Saúde Educ 2010; 14(34): 593-605. ⁵5. World Health Organization. Preventing chronic diseases: a vital investment.; Geneva: WHO 2005. ⁶6. World Health Organization. National cancer control programmes, policies and managerial guidelines. 2 ed.; Geneva: WHO 2002..

NCD surveillance is of great importance in public health, as it is a tool for knowing the distribution, magnitude and trend of these diseases, and their risk factors in the population and identify their social, economic, and environmental conditions, aiming to support the planning, implementation, and evaluation of prevention and control actions⁷7. Malta DC, Moura L, Silva Junior JB. Epidemiologia das doenças crônicas não transmissíveis (DCNT) no Brasil. In: Roquayrol MZ, Gurgel M. Epidemiologia e Saúde. Rio de Janeiro: Medbook; 2013. p. 273-96..

Aimed at structuring NCD surveillance, the Ministry of Health developed, starting in 2003, a set of initiatives for gaining knowledge on the distribution, the magnitude and trends of chronic diseases and their risk factors, and supporting public health promotion policies. As part of the process, Brazil outlined a system based on the information on risk factors and mortality and risk factor surveys, which are divided in household- and telephone-based surveys and in specific populations, such as school-aged children⁸8. Malta DC, Leal MC, Costa MFL, M-Neto OL. Inquéritos Nacionais de Saúde: experiência acumulada e proposta para o inquérito de saúde brasileiro. Rev Bras Epidemiol2008; 11(Supl. 1): 159-67..

Thus, the National Health Survey (PNS) in 2013 - the most comprehensive survey on health and its determinants ever held in the country - makes up the NCD surveillance system and includes both information about risk factors and morbidity.

The objective of this study was to describe the major NCDs in the country according to the information collected from individuals aged 18 years or older, all respondents of the PNS in 2013.

METHODS

The PNS is a household survey that is part of the Integrated Household Surveys System (SIPD), of the Brazilian Institute of Geography and Statistics (IBGE), and uses the Master Sample of this system, with greater geographical spread and gain of accuracy in the estimates⁹9. Szwarcwald CL, Malta DC, Pereira CA, Vieira MLFP, Conde WL, et al. Pesquisa Nacional de Saúde no Brasil: concepção e metodologia de aplicação. Ciênc Saúde Colet 2014; 19(2): 333-42..

With its own design, developed specifically to collect health information, the PNS is designed to estimate several indicators with adequate precision. The PNS is a survey conducted by IBGE in partnership with the Ministry of Health and is the most complete survey on health and its determinants⁹9. Szwarcwald CL, Malta DC, Pereira CA, Vieira MLFP, Conde WL, et al. Pesquisa Nacional de Saúde no Brasil: concepção e metodologia de aplicação. Ciênc Saúde Colet 2014; 19(2): 333-42..

The sample size was defined based on the desired accuracy level for estimating the number of indicators of interest, which are basically proportions of people in certain categories.

The sample plan employed was conglomerated sampling in three stages, with stratification of the primary units. The census tracts, or set of tracts, form the primary sampling units (PSUs), households are the secondary units, and residents aged 18 years and older define the tertiary units. Within each selected household, one resident aged 18 years or older was selected to respond to the specific questionnaire, also by simple random sampling, from a list of residents made during the interview.

Sample weights were set for the PSUs, households, and all its residents and the weight for the selected resident. The latter was calculated considering the weight of the corresponding household, the probability of the resident selection, nonresponse adjustment by sex, and calibration by the total population by sex and age groups estimated with the weight of all residents.

All the information collection agents, supervisors, and coordinators of the PNS were trained to thoroughly understand the entire survey. The interviews were conducted with the use of personal digital assistants (PDAs) and handheld computers that were properly programed for the critic process of the variables.

The respondent of the individual questionnaire was selected at random from the residents of each household, and this individual was asked questions about previous diagnosis of several NCDs. Interviewers asked if "any doctor has given you the diagnosis of hypertension (high blood pressure)?" The response options were yes; yes, but only during pregnancy (for women); or no. The response considered was "yes."

For diabetes, it was similar: "Has a doctor ever given you the diagnosis of diabetes?" The response options were yes; yes, but only during pregnancy (for women); or no. The response considered was yes.

The same question was posed to other morbidities [heart disease, stroke, asthma, arthritis or rheumatism, work-related musculoskeletal disorders (WMSDs), cancer, and chronic kidney disease (CKD)]. The response options were yes or no.

In the case of back pain, the question asked was: "Do you have any chronic back problem, such as back pain, neck pain, low back pain or sciatica, vertebrae or disc problems?" Then, response options were yes or no.

For depression, the question was: "Has a doctor or mental health professional, such as a psychiatrist or psychologist, ever given you the diagnosis of depression?" The response options were yes or no. For other mental illnesses, the question was: "Has a doctor or mental health professional, such as a psychiatrist or psychologist, ever given you the diagnosis of other mental disorders [schizophrenia, bipolar disorder, psychosis, or obsessive-compulsive disorder-OCD]?" The response options were yes or no. The PNS questionnaire is available online at: http://www.pns.icict.fiocruz.br/arquivos/Novos/Questionario%20PNS.pdf.

This study examined the following indicators related to NCDs:

The total number of individuals aged 18 years and older who reported having at least one of these NCDs was calculated; then, the proportions and the total subjects with each above-mentioned NCD was calculated, according to sex.

Moreover, the proportion of individuals aged 18 years or older who reported high/very high degree of limitation in activities of daily living was calculated and the degree of incapacity declared by the respondent for each of the NCDs. The individuals who responded that the disease limits them intensely/very intensely were considered.

All indicators were presented by gender, with 95% confidence intervals (95%CI). Data were analyzed using Stata software, version 11.0, using the survey module, which incorporates the effects of complex samples.

The PNS was approved by the National Research Ethics Committee, under protocol number 328.159 in 26 June, 2013. All the subjects were consulted, informed, and agreed to participate.

RESULTS

At the end of collection, the records from the interviews in 64,348 households and with 60,202 individuals were obtained, which resulted in a nonresponse rate of 8.1%.

Of the total respondents in the PNS, the prevalence of individuals who reported having at least one NCD was of 45.1% and the prevalence was 50.4% and 39.2% for female and male subjects, respectively. It is estimated that there are more than 66 million Brazilians with a previous diagnosis of some NCD (Table 1).

The region with the highest prevalence of individuals with NCDs was the southern region, with 52.1%, followed by the southeastern (46.1%), midwestern (43.9%), northeastern (42.2%), and northern (37.2%) regions. Still, the Brazilian state with the highest prevalence of NCDs was Rio Grande do Sul, with 54.2%, and the other states of the southern region also showed high prevalence of NCDs: Paraná (52.3%) and Santa Catarina (48.4%). The southeastern region, which concentrates most of the population, showed a high prevalence in the states of São Paulo (46.9%) and Minas Gerais (48.0%). Among the states of north, Pará showed the lowest prevalence, with 34.4% or, in absolute numbers, 1.7 million (Table 1).

Regarding morbidities, hypertension was the most reported among the respondents, with a prevalence of 21.4% in the population aged 18 years or older or, in absolute numbers, approximately, 31 million individuals. As a result, the most mentioned diseases were chronic back problems (18.5%), depression (7.6%), arthritis (6.4%), and diabetes (6.2%). Other diseases showed a prevalence lower than 5% (Table 2).

For male subjects, high blood pressure was the most reported among the respondents, with a prevalence of 18.3%, followed by chronic back problems (15.5%), diabetes (5.4%), depression, and heart disease (3.9%). Other diseases showed a prevalence lower than 4% (Table 3).

For female subjects, hypertension was also the most reported disease, with a prevalence of 24.2%, followed by chronic back problems (21.1%), depression (10.9%), arthritis or rheumatism (9.0 %), and diabetes (7.0%). Other diseases showed a prevalence lower than 5% (Table 4).

With regard to the intense/very intense degree of physical limitation in activities of daily living referred for the NCDs investigated, other mental illnesses (schizophrenia, bipolar disorder, psychosis, or OCD) were mentioned by the most respondents, with 37.6%, followed by stroke (25.5%), arthritis or rheumatism (17.1%), chronic back problems (16,4%), WMSDs, and asthma (15.7%) (Table 5).

DISCUSSION

The PNS revealed that the burden of morbidity of NCDs in the country is high, as about 45% of the population reports at least one chronic disease, and women report more NCDs than men. The medical diagnosis of hypertension is reported by about one-fifth of the adult population, followed by chronic back problems. Other NCDs such as depression and diabetes also showed high frequencies. Other mental disorders showed the highest degree of limitation, followed by stroke, arthritis, and back pain.

Currently, NCDs are the public health problem of greater magnitude, because they represent the highest proportion of causes of death in the country¹⁰10. Schmidt MI, Duncan BB, Silva GA, Menezes AM, Monteiro CA, et al. Doenças crônicas não transmissíveis no Brasil: carga e desafios atuais. Lancet 2011; 61-74.. Brazil has experienced, in recent decades, significant changes in its pattern of mortality and morbidity, owing to epidemiological, demographic, and nutritional transitions. Regarding the epidemiological transition, there was a significant reduction in infectious diseases and an increase in NCDs, accidents, and violence¹¹11. Malta DC, Morais Neto OL, Silva Junior JB. Apresentação do plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis no Brasil, 2011 a 2022.Epidemiol Serv Saúde 2011; 20(4): 425-38. ¹²12. Malta DC, Cezário AC, Moura L, Morais Neto OL, Silva Júnior JB. Construção da vigilância e prevenção das doenças crônicas não transmissíveis no contexto do sistema único de saúde. Epidemiol Serv Saúde2006; (15): 47-64..

The demographic, epidemiological, and nutritional transition processes; urbanization; and social and economic growth contribute to the increased risk of developing chronic diseases by the population¹⁰10. Schmidt MI, Duncan BB, Silva GA, Menezes AM, Monteiro CA, et al. Doenças crônicas não transmissíveis no Brasil: carga e desafios atuais. Lancet 2011; 61-74. ¹¹11. Malta DC, Morais Neto OL, Silva Junior JB. Apresentação do plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis no Brasil, 2011 a 2022.Epidemiol Serv Saúde 2011; 20(4): 425-38..

According to the National Household Sample Survey (PNAD) conducted in 2008, 31.3% of respondents said they experienced at least one chronic disease¹³13. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional por Amostra de Domicílios. Panorama da Saúde no Brasil: acesso e utilização dos serviços, condições de saúde e fatores de risco e proteção à saúde (PNAD 2008). Rio de Janeiro: IBGE; 2010b.. Data from the 2013 PNS showed 45.1% cases of NCDs. However, it is noteworthy that the PNAD interviewed individuals aged 15 years or older, in a smaller sample than the PNS in terms of census tracts. Furthermore, the questionnaires are different. Thus, the comparison between the indicators is limited.

Mortality studies point to an increase in the proportion of deaths from NCDs and also increasing the proportion of hospitalizations¹⁴14. Malta DC, Prestes IV, Oliveira JCG, Moura L, Nunes ML, Oliveira MM, et al. Morbidade hospitalar e ambulatorial em Doenças Crônicas não Transmissíveis no Sistema Único de Saúde - DCNT. In: Ministério da Saúde. Saúde Brasil 2012: uma análise da situação de saúde e dos 40 anos do Programa Nacional de Imunizações. Ministério da Saúde. 2013. p. 243-72.. Brazil is an aging country, and, as the elderly people tend to have a higher prevalence of NCDs, the burden of chronic diseases in the country tends to increase, requiring a new health-care model for this population¹⁵15. Lima-Costa MFF, Matos DL, Camargos VP, Macinko J. Tendências em dez anos das condições de saúde de idosos brasileiros: evidências da Pesquisa Nacional por Amostra de Domicílios (1998, 2003, 2008). Ciênc Saúde Colet 2011; 16(9): 3689-96..

In all the self-reported NCDs, women showed a higher prevalence than men. In self-reported studies, it is common for women to report more high blood pressure, owing to their increased demand for health services and a greater opportunity for medical diagnosis¹⁵15. Lima-Costa MFF, Matos DL, Camargos VP, Macinko J. Tendências em dez anos das condições de saúde de idosos brasileiros: evidências da Pesquisa Nacional por Amostra de Domicílios (1998, 2003, 2008). Ciênc Saúde Colet 2011; 16(9): 3689-96. ¹⁶16. Lima-Costa MFF, Peixoto SV, Firmo JOA. Validade da hipertensão arterial autorreferida e seus determinantes (Projeto Bambuí). Rev Saúde Pública 2004; 38(18): 637-42. ¹⁷17. Nogueira D, Faerstein E, Coeli CM, Chor D, Lopes CS, Werneck GL. Reconhecimento, tratamento e controle da hipertensão arterial: Estudo Pró-Saúde, Brasil. Rev Panam Salud Publ 2010; 27(2): 103-9..

Hypertension was the most mentioned disease, as consistent with other studies that show that it is the most prevalent circulatory disease and often associated with more severe outcomes, such as cardiovascular disease (CVD), fatal and nonfatal cerebrovascular disease, and kidney failure¹⁸18. Ribeiro MCSA, Barata RB, Almeida MF, Silva ZP. Perfil sociodemográfico e padrão de utilização de serviços de saúde para usuários e não-usuários do SUS - PNAD 2003. Ciênc Saúde Colet 2006; 11(4): 1011-22. ¹⁹19. Ribeiro AB. Atualização em hipertensão arterial: clínica, diagnóstico e terapêutica. São Paulo: Atheneu; 2007.. PNAD 2008¹³13. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional por Amostra de Domicílios. Panorama da Saúde no Brasil: acesso e utilização dos serviços, condições de saúde e fatores de risco e proteção à saúde (PNAD 2008). Rio de Janeiro: IBGE; 2010b. showed 14% of hypertension in the population aged 15 years or older. More recently, in the Brazilian state capitals, Vigitel 2011 found an average prevalence of 22.7% in individuals aged 18 years or older²⁰20. Andrade SSCA, Malta DC, Iser BM, Sampaio PC, Moura L. Prevalência de hipertensão arterial autorreferida nas capitais brasileiras em 2011 e análise de sua tendência de 2006 a 2011. Rev Bras Epidemiol 2014; 17(Supl 1): 215-26.. Self-reported hypertension, diagnosed previously, was higher among women.

Several studies point out that before the age of 50 or menopause, the prevalence of hypertension is lower among women, suggesting a protective effect of estrogen²¹21. Pereira M, Lunet N, Azevedo A, Barros H. Differences in prevalence, awareness, treatment and control of hypertension between developing and developed countries. J Hypertension 2009;27(5): 963-75. ²²22. Victor RG. Hipertensão arterial. In: Ausielo D, Goldman L. Cecil - Tratado de medicina interna. 23 ed. Rio de Janeiro: Elsevier; 2009. p. 506-37.. Still, the WHO points out that, in adults older than 25 years, the prevalence rates are higher among men²³23. World Health Organization. World Health Statistics. WHO; 2012. Disponível em: Disponível em: http://apps.who.int/iris/bitstream/10665/44844/1/9789241564441_eng.pdf . (Acessado em 16 de abril de 2015).
http://apps.who.int/iris/bitstream/10665... . Therefore, future hypertension analyzes measured by the PNS may explain whether the difference reflects the bias of higher demand for services in women or if it is real.

Diabetes mellitus is a global health problem, whose prevalence, estimated by the WHO in 2010, is of 6.4% among adults aged 20 - 79 years and with an annual increase of 2.2%²⁴24. Shaw JE, Sicree RA, Zimmet PZ. Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes Res Clin Pract 2010; 87(1): 4-14.. According to the WHO, in 2008, diabetes was responsible for 1.3 million deaths and about 4% of premature deaths (< 70 years)¹1. Brasil. Ministério da Saúde. Plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis (DCNT) no Brasil, 2011-2022. Brasília: Ministério da Saúde; 2011.. In addition, it is associated with limitations and disabilities. The PNS pointed to prevalence values that were very close to the global data²2. World Health Organization. Global status report on noncommunicable diseases 2010. Geneva: WHO; 2011., 6.2% (95%CI 5.9 - 6.6), and near the data from Vigitel 2013²⁵25. Brasil. Ministério da Saúde. Vigitel 2013: Vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: Ministério da Saúde 2014. in the Brazilian state capitals, 6.9% (95%CI 6.5 - 7.3). This is the first research that points out the high degree of disability in diabetes 7% (95%CI 6.5 - 7.5), or 642,000 Brazilians, who have intense or very intense limitations owing to diabetes. These data reinforce the importance of disease prevention and health promotion.

Musculoskeletal pain and problems may affect a large portion of the population, causing economic impact and impact in the quality of life of individuals. Among the chronic back problems, chronic lower back problems are the most common, affecting mainly the population of working age. In the PNS, this was the second most reported NCD (18.5%). There are many population studies in the country about back pain. According to data from the Brazilian Ministry of Social Welfare, back pain has been the main reason for absence from work²⁶26. Brasil. Ministério da Previdência Social. Relação das 10 maiores frequências de auxílios-doença concedidos segundo os códigos da CID-10 - Acumulado Ano 2007. 2007 . Disponível em: http://www.mps.gov.br/arquivos/office/3_081014-103849-820.pdf. (Acessado em 16 de abril de 2015).
http://www.mps.gov.br/arquivos/office/3_... .

Data from the 2003 and 2008 PNAD showed that self-reported arthritis/rheumatism was the third most common chronic disease in the Brazilian adult population, affecting about 6% of the population in both the surveys, two times higher in women than in men²⁷27. Barros MBA, Francisco PMSB, Zanchetta LM, Cesar CL. Tendências das desigualdades sociais e demográficas na prevalência de doenças crônicas no Brasil, PNAD: 2003-2008. Ciênc Saúde Colet 2011; 16(9): 3755-68.. The PNS pointed to lower prevalences than the PNAD, 3.5% of people with the disease. Methodological differences, especially in the question, here related to previous medical diagnosis, explain in part this difference.

The WMSDs, characterized as painful and damaging disorders caused by overuse or excessive activity of some part of the musculoskeletal system, often resulting from physical activities related to work, also cause negative consequences for individuals and for the public expenses²⁸28. Brasil. Ministério da Previdência Social. Instrução Normativa nº 98, do Instituto Nacional de Seguro Social, de 5 de dezembro de 2003. Aprova Norma Técnica sobre lesões por esforços repetitivos - LER ou distúrbios osteomusculares relacionados ao trabalho - DORT. Brasília: Diário Oficial da União; 10 dez 2003.. The PNS evaluated the issue of WMSDs for the first time, allowing a national overview of these diseases. It is present in 2.4% of the population, predominantly in women, almost double, of which 16.4% reported inability for activities of daily living, revealing the size of the disability and how it affects people, work, business, and the health-care system.

Depression is an emotional disorder characterized mainly by changes in mood, decreased energy, and decreased activity. It can vary between lighter and more severe episodes. Studies show sociodemographic differences in the prevalence of depression. For example, among women, depression is twice as common as in men²⁹29. Rombaldi AJ, Silva MC, Gazalle FK, Azevedo MR, Hallal PC. Prevalência e fatores associados a sintomas depressivos em adultos do sul do Brasil: estudo transversal de base populacional. Rev Bras Epidemiol 2010; 13: 620-9. ³⁰30. Van de Velde S, Bracke P, Levecque K. Gender differences in depression in 23 European countries. Cross-national variation in the gender gap in depression. Soc Sci Med 2010; 71: 305-13.. The PNS first explored the subject and the data are startling: 7.6% of the population has been diagnosed by a physician or mental health professional. Depression affects almost three times more women, and about 11.8% reported disability owing to the illness.

Asthma is characterized as a chronic disease that affects the airways and other structures of the lungs. According to the WHO, asthma ranks first in the prevalence of chronic respiratory diseases, affecting 300 million people worldwide³¹31. World Health Organization. 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases. Geneva: WHO 2014.. In Brazil, it would be about 6.4 million people, or 4.4% of the adult population, with 15.7% reporting disability from the disease. Asthma is responsible for a large number of hospital admissions, resulting in a significant cost to the Unified Health System (SUS)³²32. Alfradique ME, et al. Internações por condições sensíveis à atenção primária: a construção da lista brasileira como ferramenta para medir o desempenho do sistema de saúde (Projeto ICSAP - Brasil). Cad Saúde Pública 2009; 25(6): 1337-49..

CKD is characterized by kidney injury or impaired renal function for three or more months, regardless of the diagnosis that caused the injury or the reduction in function. CKD is a public health problem that impacts individuals and their families and society and the health system. The main risk factors associated with CKD are diabetes mellitus, hypertension, family history of renal disease, and aging³³33. Moura L, Schmidt MI, Duncan BB, Rosa RS, Malta DC, Stevens A, et al. Monitoramento da doença renal crônica terminal pelo subsistema de Autorização de Procedimentos de Alta Complexidade - Apac - Brasil, 2000 a 2006. Epidemiol Serv Saúde 2009; 18(2): 121-31..

Study based on analyses of the Subsystem for Authorization of High Complexity Renal Replacement Therapy Procedure estimated the incidence of CKD for the period 2000-2006 for the country in 119.8/1,000,000 inhabitants/year. The prevalence and incidence increase over the progression of age³³33. Moura L, Schmidt MI, Duncan BB, Rosa RS, Malta DC, Stevens A, et al. Monitoramento da doença renal crônica terminal pelo subsistema de Autorização de Procedimentos de Alta Complexidade - Apac - Brasil, 2000 a 2006. Epidemiol Serv Saúde 2009; 18(2): 121-31.. The findings of PNS of 1.4% prevalence of CKD is absolutely unprecedented and reveals the extent of the disease in the country, because it results in intense disability (11.9%) and burdens health services, especially National Health System and the individuals and families.

Stroke is a leading cause of death and disability worldwide. It is estimated that, in 2005, about 5.7 million deaths were owing to stroke, and 87% occurred in low- and middle-income countries³⁴34. Strong K, Mathers C, Bonita R. Preventing stroke: saving lives around the world. Lancet Neurol 2007; 6(2): 182-7.. One study on the mortality trends by stroke in Brazil for individuals aged 30 years or older, from 2000 to 2009, observed an increasing trend in mortality rates by 2006 and a subsequent decline until 2009³⁴34. Strong K, Mathers C, Bonita R. Preventing stroke: saving lives around the world. Lancet Neurol 2007; 6(2): 182-7.. Still, the Longitudinal Study of Adult Health (ELSA-Brazil), conducted in 2014, found a prevalence of 1.3% in the population aged 35 - 74 years³⁵35. Garritano CR, Luz PM, Pires MLE, Barbosa MTS, Batista KM. Análise da Tendência da Mortalidade por Acidente Vascular Cerebral no Brasil no Século XXI. Arq Bras Cardiol 2012; 98(6): 519-27..

CVDs are the leading cause of death in Brazil. Although mortality has decreased over the years in Brazil (about 34% for cerebrovascular disease and 44% for other heart diseases), it remains high. In 2004, mortality attributable to CVD was of 286 per 100,000 people. Still, CVDs generate the highest costs in relation to hospital admissions¹⁰10. Schmidt MI, Duncan BB, Silva GA, Menezes AM, Monteiro CA, et al. Doenças crônicas não transmissíveis no Brasil: carga e desafios atuais. Lancet 2011; 61-74.. It is estimated that, for 2007, 12.7% of hospitalizations in Brazil were owing to CVD. According to the data from ELSA-Brazil, the prevalence of coronary heart disease and stroke in people aged 35 - 74 years were of 4.7 and 1.7%, respectively³⁶36. Schmidt MI, Duncan BB, Mill JG, Lotufo PA, Chor D, Barreto SM, et al. Cohort profile: Longitudinal study of adult health (ELSA-Brasil). Int J Epidemiol 2014; 1-8..

CONCLUSION

The PNS revealed a rich and disturbing panel in the country with a high burden of NCDs and disabilities, which may increase owing to the aging population. It is fundamental to monitor NCDs, its morbidity and mortality burden, and risk factors. Strengthening the surveillance is a national and global priority. The Ministry of Health has invested in improving coverage and quality of data on mortality and morbidity, and the PNS completes the surveillance panel, setting an invaluable baseline.

There is a strong evidence that correlates the social determinants, such as education, occupation, income, gender, and ethnicity, with the prevalence of NCDs and risk factors²2. World Health Organization. Global status report on noncommunicable diseases 2010. Geneva: WHO; 2011.. In Brazil, despite the existence of SUS, a free and universal health-care system, the individual cost of a chronic disease is still quite high, owing to aggregate costs, sick leave, and loss of productivity, which contributes to the impoverishment of families. Estimates for Brazil suggest that the loss of productivity at work and reduced family income resulting from only three NCDs (diabetes, heart disease, and stroke) will lead to a loss of US$ 4.18 billion in the Brazilian economy between 2006 and 2015³⁷37. Abegunde DO, Mathers CD, Adam T, Ortegon M, Strong K. The burden and costs of chronic diseases in low-income and middle-income countries. Lancet2007; 370: 1929-38..

Regarding the burden of morbidity and mortality from NCDs, they are huge challenges for governments, health managers, and the general public³⁸38. Alwan A, MacLean DR, Riley LM, d'Espaignet ET, Mathers CD, Stevens AG, et al. Monitoring and surveillance of chronic noncommunicable diseases: progress and capacity in high-burden countries. Lancet 2010; 376: 1861-68. ³⁹39. Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380: 2095-128.. One must also consider the increasing elderly population and the disease burden in the coming decades, with an increasing growth in demand for health services. The evidence in the current scientific-technical production point to the benefits of integrated public and intersectoral policies in response to these challenges³¹31. World Health Organization. 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases. Geneva: WHO 2014. ³⁸38. Alwan A, MacLean DR, Riley LM, d'Espaignet ET, Mathers CD, Stevens AG, et al. Monitoring and surveillance of chronic noncommunicable diseases: progress and capacity in high-burden countries. Lancet 2010; 376: 1861-68. ³⁹39. Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380: 2095-128..

The production of information and analysis of the health situation can support the implementation of sectoral and intersectoral strategies, implementing full care for NCDs and their risk factors. In addition, the improvement of health services, especially the qualification of primary care, can effectively respond to the double burden of illness in middle- and low-income countries¹1. Brasil. Ministério da Saúde. Plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis (DCNT) no Brasil, 2011-2022. Brasília: Ministério da Saúde; 2011. ²2. World Health Organization. Global status report on noncommunicable diseases 2010. Geneva: WHO; 2011. ¹⁰10. Schmidt MI, Duncan BB, Silva GA, Menezes AM, Monteiro CA, et al. Doenças crônicas não transmissíveis no Brasil: carga e desafios atuais. Lancet 2011; 61-74..

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