Risk Dialogue Series
Health Risk Factors Brazil
Sw
iss Re
Risk D
ialogue Series on H
ealth Risk Factors B
razil
In collaboration with
Contents
Prefaceïżœ 3MargoïżœBlack,ïżœSwissïżœReinsuranceïżœCompanyJosephïżœBrain,ïżœHarvardïżœSchoolïżœofïżœPublicïżœHealth
SEARCH â The search for health data and insights from Brazil 5EduardoïżœLaraïżœdiïżœLauro,ïżœSwissïżœReinsuranceïżœCompanyRolfïżœSteiner,ïżœSwissïżœReinsuranceïżœCompany
Overview of health risk factors in Brazilïżœ 15MarciaïżœC.ïżœCastro,ïżœHarvardïżœSchoolïżœofïżœPublicïżœHealthïżœ
Risk factors for cardiovascular disease in Brazil: Time trends and current statusïżœ 21MarciaïżœC.ïżœdeïżœOliveiraïżœOtto,ïżœTheïżœUniversityïżœofïżœTexas
Two decades of research linking air pollution to cardiovascular disease in Brazil: A systematic reviewïżœ 29JenniferïżœL.ïżœNguyen,ïżœHarvardïżœSchoolïżœofïżœPublicïżœHealthDouglasïżœW.ïżœDockery,ïżœHarvardïżœSchoolïżœofïżœPublicïżœHealth
Understanding the global risk of the tobacco epidemic and its trajectory in an emerging market nation 35HillelïżœR.ïżœAlpert,ïżœHarvardïżœSchoolïżœofïżœPublicïżœHealth
Time trends of physical activity practice in Brazilïżœ 45GrĂ©goreïżœI.ïżœMielke,ïżœUniversidadeïżœFederalïżœdeïżœPelotasPedroïżœC.ïżœHallal,ïżœUniversidadeïżœFederalïżœdeïżœPelotasïżœI-MinïżœLee,ïżœHarvardïżœSchoolïżœofïżœPublicïżœHealth
Acknowledgementïżœ 53
Sponsorsïżœ 54
Swiss Reâ RiskâDialogueâSeriesâ 3
Preface
Dearâreader
WeâareâveryâpleasedâtoâwelcomeâyouâtoâthisâeditionâofâtheâRiskâDialogueâSeriesâonâHealthâRiskâFactorsâinâBrazil.â
Non-communicableâchronicâdiseasesâ(NCDs)âhaveâbecomeâincreasinglyâprevalentâinâhighâgrowthâandâemergingâmarkets.âItâisâessentialâtoâbetterâunderstandâtheseâtrends,âbothâfromâaâpublicâhealthâperspectiveâandâinâorderâtoâbuildâsustainableâlifeâandâhealthâinsuranceâpools.
ThisâpublicationâisâpartâofâtheâjointâresearchâcollaborationâbyâSwissâReâandâtheâHarvardâSchoolâofâPublicâHealthâ(HSPH).âItâdescribesâtheâresearchâundertakenâbyâ45âcolleaguesâfromâbothâinstitutions.âItâisâanâimportantâcomponentâofâwhatâweâcallâtheâSystematicâExplanatoryâAnalysesâofâRiskâfactorsâaffectingâCardiovascularâHealthâ(SEARCH)âproject.âTheâaimâofâourâcollaborationâisâtoâclarifyâtheârelationshipâbetweenâriskâfactorsâandâhealthâoutcomesâinâtheârapidlyâevolvingâcountriesâofâBrazil,âChina,âIndiaâandâMexico.âTheirâhealthâprofileâisâchangingâswiftlyâandâsignificantlyâwithâeconomicâgrowth.âNCDsâareârisingârapidly,âcreatingâaâmajorâchallengeâforâpublicâandâprivateâprovidersâandâfundersâofâhealthâcare.â
Brazilâisâaâvastâcountry.âDespiteâextensiveâpublicâhealthâcampaigns,âpartsâofâBrazilâstillâstruggleâwithâinfectiousâdiseasesâthatâareâcharacteristicâofâdevelopingâcountries.âAtâtheâsameâtime,âitâisâbesetâbyâaârisingârateâofâNCDs,âaâsituationâcompoundedâbyâtheâcountryâsâageingâpopulation.âAsâwithâotherâemergingâmarkets,âBrazilâhasâaârapidlyâgrowingâmiddleâclass.âThisâmiddleâclassâhasâalreadyâexpressedâfrustrationâatâtheâin-sufficientâpublicâservices,âsuchâasâpublicâtransport.âWithâincreasingâdemandsâonâtheâhealthâsystem,âaccessâtoâadequateâhealthcareâhasâtheâpotentialâtoâbecomeâanotherâdivisiveâpoliticalâissue.â
Theseâchallengesâareânotâinsurmountable.âSwissâReâbelievesâtheâneedâforâgreaterâhealthâcoverageâcanâbeâasâmuchâanâopportunityâasâaâthreat.âInsuranceâcanâplayâaâvaluableâroleâinâexpandingâaccessâtoâhealthcareâinâanâaffordableâandâreliableâmanner.âWithâtheâSEARCHâarticles,âweâhopeâtoâimproveâourâunderstandingâofâtheâstateâofâhealthâinâBrazil.â
Withâbestâregardsâ
MargoâBlackâ JosephâBrainHeadâofâReinsuranceâ DrinkerâProfessorâofLatinâAmericaâSouthâââ EnvironmentalâPhysiologySwissâReinsuranceâCompanyââ HarvardâSchoolâofâPublicâHealth
Swiss Reâ RiskâDialogueâSeriesâ 5
SEARCH â The search for health data and insights from Brazil
EduardoâLaraâdiâLauro,âRolfâSteiner Brazil offers universal health coverage. However, its health services are under pressure from demographic change and the rise in chronic conditions. Private insurance schemes could be a valuable component in the provision of future health service solutions. Insurers can only improve products and pricing with good data and an understanding of future trends. The SEARCH project attempts to provide a basis for improved understanding of the major health drivers in Brazil.
Lifeâandâhealthâinsuranceâandâdata
Lifeâandâhealthâinsuranceâisâtheâprovisionâofâcoverageâfromâaâvoluntaryâriskââpoolâofâindividualsâwhoâperceiveâthemselvesâasâhavingâaâsimilarâriskâprofile.ââFromâanâinsuranceâperspectiveâthereâareâthreeâmainâgenericâreasonsâwhyâmoreââdataâisâbeneficial:
(i)â âControllingâinsuranceârisk:âTheâlifeâinsuranceâriskâlandscapeâisâconstantlyâshifting.âPandemicsâareâpotentiallyâtheâmostâdramaticâexampleâofâthisâââaâsuddenâillnessâthatâmayâtakeâmanyâ(relatively)âyoungâlives.âWeâareâcurrentlyâwitnessingâaâdramaticâincreaseâinâtheâprevalenceâofâchronicâdiseases,âsuchâasâcancerâandâdiabetes.âTheseâareâfrequentlyâtheâproductâofâchangingâlifestyles.âEqually,ââsocietalâchangesâcanâprolongâlives.âNewâtreatmentsâofferâtheâpotentialâtoâreduceâprematureâdeathsâfromâcertainâdiseases.âAllâofâtheseâfactorsâwillâaffectâtheâfutureâclaimsâexperienceâforâlifeâandâhealthâprivateâinsuranceâpoolsâandâinfluenceâhowâinsurersâpriceâtheirâproducts.â
(ii)â âExtendingâproductâcoverage:âVoluntaryâprivateâlifeâandâhealthâinsuranceâcannotâbeâallâinclusive.âRelativelyâhealthyâindividualsâwillânotâwillinglyâacceptâhigherâpremiumsâinâaâpoolâwithâhighâriskâindividuals.âCertainâexclusionsâareâinevitableâinâaâprivateâvoluntaryâinsuranceâsystem.âHowever,âinsuranceâcompanies,âusingâbetterâdata,âareâableâtoâextendâcoverageâandâcreateâdifferentiatedâratingâsystems,âclassifyingâapplicantsâasâpreferred,ânormalâorâsubnormalârisks.âAânotableâsuccessâinârecentâyearsâhasâcomeâwithâextendingâcoverageâtoâHIVâinfectedâindividualsââinâSouthâAfrica1.â
(iii)ââCreatingânewâproducts:âLifeâandâhealthâcoverageâhasâtraditionallyâbeenâdistributedâthroughâagents,âwhoâareârequiredâtoâgoâthroughâaâpotentiallyâlongâunderwritingâprocessâwithâtheirâclients.âThisâcanâbeâaâbarrierâtoâretailing,âparticularlyâinâaâdigitalâage,âinâwhichâconsumersâcanâpurchaseâmostâproductsâquicklyâandâeasilyâwithâaâclickâofâaâbutton.âInsurersâareâseekingâtoâuseâimprovedâdataâtoâofferâlifeâandâhealthâproductsâthatâcanâquicklyâandâeasilyâbeâofferedâwithâminimalâunderwriting2.
Lifeâandâhealthâinsuranceâinvolvesâprovidingâcoverageâtoâaâvoluntaryâriskâpoolâofâindividualsâwithâaâsimilarâriskâprofile.â
HavingâmoreâdataâhelpsâinsurersâcontrolâinsuranceâriskââŠ
âŠâextendâproductâcoverage
âŠâandâcreateânewâproducts.
6â Swiss Reâ RiskâDialogueâSeries
Dataâandâemergingâmarkets
Emergingâmarketsâareârelativelyâunderinsured.âInâ2012,âtheyâaccountedâforâonlyâ15%âofâtheâUSDâ2621âbillionâinâglobalâlifeâandâhealthâpremiums3.âWithâeconomicâgrowth,âandâparticularlyâtheâgrowthâofâtheâmiddleâclass,âthisâfigureâisâexpectedâtoâgrowâsubstantiallyâinâtheâcomingâyears.
Majorâinsurersâareâalreadyâwellâplacedâinâtheâcompetitiveâmarketâforânewâemergingâmarketâinsuranceâcustomers.âFrequently,âhowever,âstandardsâofâdataâreportingâareânotâwhatâtheyâhaveâexperiencedâinâtheirâownâdevelopedâmarkets.âSEARCHâisâoneâattemptâtoâcorrectâandâaddressâthisârelativeâlackâofâhistoricâdata.â
Evenâwhereâdataâisâquiteâgood,âtheâhealthâofâmanyâemergingâmarketsâisâinâaâstateâofâflux.âThroughoutâmostâofâhumanâhistory,âtheâleadingâcauseâofâdeathâwasâinfectiousâdisease.âAsâcommunicableâdiseasesâareâcontrolledâandâeliminated,âandâasâpopulationsâinâmanyâcountriesâhaveâstartedâtoâage,âchronicâdiseasesâareâbecomingâmoreâprevalent.âDiabetes,âforâexample,âwasâvirtuallyâunknownâinâmanyâemergingâmarketsâonlyâthirtyâyearsâago.âHowever,âdueâtoâsignificantâchangesâinâdiet,âitâisânowâquiteâcommonplaceâ(Figureâ1).â
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Note:âWhenâcomparingâtheâ20âyearâtransitionâofâtheâleadingâcausesâofâdeathâinâBrazil,âMexicoâandâtheâUSAâfromâ1990âtoâ2010,âoneâcanâseeâdistinctiveâdifferences.âWhileâmortalityâratesâofâheartâdiseasesâdeclinedâbyâ27%âinâBrazilâandâ38%âinâtheâUSA,âtheyâonlyâdecreasedâbyâ8%âinâMexico.âWhileâstrokeâmortalityâratesâdeclinedâinâallâcountriesâatâsimilarârates,âtheâtotalâmortalityârateâperâ100â000âinâ2010âisâaboutâtwiceâasâhighâinâBrazilâasâinâMexico,âandâalmostâthreefoldâhigherâthanâinâtheâUSA.âThisâsuggestsâaâdifferenceâinâstrokeâmanagementâpracticesâorâaccessibilityâtoâstrokeâtreatmentâinâtheâthreeâcountries.âInterestingly,âdiabetesâmortalityââratesâonlyâslightlyâincreasedâinâallâcountriesâoverâtheâobservedâ20âyearâtimeâhorizon;âhowever,âtotalâdiabetesâmortalityâratesâinâ2010âinâMexicoâwereâtwofoldâhigherâthanâthoseâinâBrazilâandâ3.5âfoldâhigherâthanâinâtheâUSA.âNoteâthatâpartâofâtheâdifferencesâinâmortalityâratesâmayâbeâdueâtoâdifferencesâinâdeathâcertificateâreportingâpracticesâinâtheâthreeâcountries.ââSource:âGlobalâBurdenâofâDiseaseâ2010
Theâdisplacementâofâinfectiousâdiseaseâwithâchronicâconditionsâhasâevolvedâoverâmanyâdecadesâinâdevelopedâmarkets.âTheâpaceâofâchangeâisâfarâmoreârapidâinâmanyâemergingâmarkets;âtoâtheâpointâthatâsomeâemergingâmarketsâareâstillâcopingâwithâseriousâinfectiousâdiseasesâwhileâhavingâtoâdealâwithâtheâriseâinâchronicâdiseases.ââThisâsuddenâshiftâtowardsâchronicâdiseaseâalsoâmeansâthatâinsurersâmustâfaceâtheâchallengeâofâanticipatingâfutureâdiseaseâtrendsâ(Figureâ2).â
Inâ2012,âemergingâmarketsâaccountedâforâ15%âofâtheâUSDâ2621âbillionâinâglobalâlifeâandâhealthâpremiums.
However,âdataâisâoftenâlackingâinâemergingâmarkets.
Chronicâdiseasesâareâbecomingâmoreâprevalent.âDiabetes,âwhichâwasâvirtuallyâunknownâinâmanyâemergingâmarketsâonlyâthirtyâyearsâago,âisânowâquiteâcommonplace.
Figureâ1:âStrokeâinâBrazilâandâdiabetesâinâMexicoâareâtheâthirdâleadingâcausesâofâdeathârightâafterâheartâdiseaseâandâcancer;âmortalityâratesââperâ100â000â(ageâadjusted)
Someâemergingâmarketsâareâstillâcopingââwithâinfectiousâdiseases,âwhileâhavingâtoââdealâwithâtheâriseâinâchronicâdiseases.
SEARCH â The search for health data and insights from Brazil
Swiss Reâ RiskâDialogueâSeriesâ 7
â
Figureâ2:âCausesâofâdeathâinâ2010âinâinsuranceâârelevantâageâintervalsâinâselectedâcountriesââ(%âtotalâmortalityâbyâageâband)
Notes:âInâtheâyoungerâageâbands,âdeathâdueâtoâtransportâinjuriesâisâtheâleadingâcauseâofâdeath;âbutâthenâquicklyâdeclinesâinâtheâolderâageâbands.âTheâkeyâdifferencesâobservedâinâtheâcountryâprofilesâcomparedâtoâtheâUSAâare:âBrazilâhasâaâhigherâstrokeâdeathârateâ(13%âvsâ4%;âageâbandâ50â69);âIndiaâhasâaâhighâdeathârateâdueâtoâcommunicableâdiseasesâ(30%âcommunicableâdiseases,â10%âinjuries;â60%ânon-communicableâdiseases;âacrossâallâageâgroups)âandâhasâaâhighâlungâdiseaseâorâCOPDâ(chronicâobstructiveâpulmonaryâdiseases)âdeathârateâ(16%âvsâ7%;âageâbandâ50â69);âChinaâhasâaâheartâdiseaseâmortalityârateâwhichâisâlowerâthanâinâtheâUSAâ(15%âvsâ24%;âageâbandâ50â69),âwhileâdeathâdueâtoâstrokeâisâsignificantlyâhigherâinâChinaâ(19%âvsâ4%;âageâbandâ50â69);âMexicoâstandsâoutâwithâaâhighâdiabetesâdeathârateâ(14%âvsâ4%;âageâbandâ50â69).ââSource:âGlobalâBurdenâofâDiseaseâ2010
Brazil
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8â Swiss Reâ RiskâDialogueâSeries
Theâultimateâeffectsâofâtheseâchangesâonâhumanâlongevityâhaveâtoâbeâseenâthroughâtheâperspectiveâofâinfrastructureâdevelopmentâandâpublicâhealth.âAgain,âthereâareâwideâvariationsâwithinâemergingâmarkets,âfromâtheârelativelyâsophisticatedâtoâthoseâwithâconsiderableâscopeâforâimprovement.âThisâisâanotherâfactorâinsurersâmustâanticipateâinâtheirâmodelling.â
SEARCHâandâBrazil
Inâmanyârespects,âBrazilâexhibitsâtheâclassicâhealthâtransitionâofâanâemergingâmarket.âChronicâdiseasesâsuchâasâcardiovascularâdiseaseâ(CVD)âandâdiabetesâhaveâemergedâasâtheâmajorâcausesâofâmortality.âThisâisâaâresultâofâtheârapidâchangeâinâageâstructureâandâhasâbeenâfuelledâbyâphysicalâinactivityâandâaâsignificantâshiftâinâdietâtowardsâtheâconsumptionâofâprocessedâfoods,âresultingâinâsignificantâincreasesâinâtheânumberââofâindividualsâwhoâareâoverweight,âobeseâandâdiabetic.âAlthoughâtheâcountryâisâvast,âitâisâsignificantlyâurbanised.âThatâhasâbroughtâwithâitâhighâlevelsâofâairâpollutionâtoââtheâmegaâcities,âwhichâisâassociatedâwithâanâincreaseâinâcardiovascularâandâcerebrovascularâmortality.âTheâhealthâtransitionâtheâcountryâhasâgoneâthroughâoverâtheâlastâdecadesâisâsummarisedâinâthisâpublication,âfollowedâbyâspecificâarticlesâaddressingâriskâfactorsâandâconditionsâcontributingâtoâtheâcountryâsâhealthâshift.â
Publicâhealthâmeasures
ThereâareâmoreâdistinctâfactorsâinâtheâoverallâhealthâlandscapeâinâBrazil.âOneâofâthoseâisâthatâpartsâofâtheâvastâcountry,ânotablyâtheâNorthâandâEast,âwereâhistoricallyâvulnerableâtoâoutbreaksâofâinfectiousâdiseases.âAlthoughâthisâhasânotâquiteâbeenâconquered,âpublicâhealthâofficialsâhaveâmadeâimpressiveâstridesâagainstâcommunicableâillnessesâsinceâtheâstartâofâtheâtwentiethâcentury.âThatâspiritâofâpublicâhealthâactivismâisâstillâaliveâandâisâbeingâusedâtoâaddressâchronicâconditions.âDespiteâbeingâtheâsecondâlargestâproducerâofâtobacco,âBrazilâhasâbeenâaheadâofâmuchâofâtheâworldâinâimplementingâlegislationâagainstâsmoking.âTheâauthoritiesâareâalsoâactivelyâpromotingâhealthierâdietsâandâmoreâexercise.â
Althoughânotâhealthârelated,âtwoâfurtherâfactorsâsignificantlyâdistinguishâlongevityââinâtheâcountryâfromâotherâemergingâmarkets.âOneâisâtheâhighâprevalenceâforâdeathâinâtrafficâaccidents;âtheâotherâisâhomicide.âBothâareâmoreâcommonâinâLatinâAmericaââthanâelsewhere.
Theâultimateâeffectsâofâtheseâchangesâonâhumanâlongevityâhaveâtoâbeâseenâthroughâtheâperspectiveâofâinfrastructureâdevelopmentâandâpublicâhealth.
Chronicâdiseasesâsuchâasâcardiovascularâdiseaseâ(CVD)âandâdiabetesâareâonâtheâriseâinâBrazil.
Brazilâhasâbeenâaheadâofâmuchâofâtheâworldâinâimplementingâlegislationâagainstâsmoking.âTheâauthoritiesâareâalsoâactivelyâpromotingâhealthierâdietsâandâmoreâexercise.
TrafficâaccidentsâandâhomicideâareâalsoâprevalentâinâBrazil.
SEARCH â The search for health data and insights from Brazil
Swiss Reâ RiskâDialogueâSeriesâ 9
Brazilâandâinsurance
Withâaâpopulationâcloseâtoâ200âmillion,âBrazilâhasâgoneâthroughâaâprosperousâdecadeâinâwhichâtheâmiddleâclassâhasâgrownâfromâ38%âtoâ54%âofâtheâpopulationâbetweenâ2002âandâ20124.âHowever,âBrazilâisânotâaâwellâinsuredâmarket.âOnlyâ25%âofâtheâpopulationâisâcoveredâbyâsomeâtypeâofâprivateâhealthâplan;âandâthatâisâlargelyâthroughâemployment.âAâSwissâReâsurveyâinâ2013âfoundâthatâonlyâ10%âofâBraziliansâhadâinsuranceâcoverâthatâwouldâprovideâincomeâprotectionâinâtheâcaseâofâseriousâillnessâ(Figureâ3)5.ââ
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1 Getting a serious illness 2 Not being able to pay for long term care 3 Not being able to retire when Iâd planned 4 Not being able to maintain my standard of living 5 Dying 6 Losing my job 7 Having to subsidise my dependents 8 Losing my home 9 Not being able to reduce my debt 10 Having to pay for childcare 11 Having to give up work to look after myself 12 None â no financial worries
Notes:âTheâthreatâofânotâreceivingânecessaryâhealthcareâtreatmentâisâtheâmajorâconcern,âwithârespondentsâfeelingâhighlyâvulnerable.âPeopleâfeelâleastâconcernedâaboutâbecomingâunemployed;âaâquarterâofârespondentsâfeelâfullyâsecureâaboutâtheirâemployability.ââSource:âSwissâRe5
Onlyâ25%âofâtheâpopulationâisâcoveredâbyâsomeâtypeâofâprivateâhealthâplanâinâBrazil.
Figureâ3:âWhatâareâyourâmainâworriesâorâconcernsâforâtheâfutureâthatâmightâleadâyouâtoâconsiderâbuyingâinsurance?
10â Swiss Reâ RiskâDialogueâSeries
SEARCH â The search for health data and insights from Brazil
Inâtheâeventâofâaâdebilitatingâcondition,âmostâhopedâthatâtheirâsavingsâwouldâcoverâanyâeventuality;âothersâplacedâ(aâsomewhatâoptimistic)âfaithâinâsocialâsecurity.âBrazilâhasâaâunitaryâhealthâsystem,âunderfundedâthroughâgeneralâtaxation.â
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1 A life insurance policy, that would pay out if I died 2 A savings or investment policy that will provide me an income in my retirement 3 A policy that would pay me an amount if I were not able to work, for a prolonged period of time, due to health issues 4 A policy to provide medical treatment privately if I need an operation or treatment for an illness 5 A policy that would pay me an amount if I contracted a serious illness, such as cancer 6 I am unsure what insurance policies I own 7 A policy that would pay my mortgage or loan payment, for a short period of time, if I were unable to work due to health 8 An agreement that my employer would continue to pay my salary in full or in part if I were unable to work due to illness 9 An agreement that my employer would pay out an amount if I died while employed by that employer 10 A policy that would pay for my residential & nursing care when I am elderly 11 None of the above
Notes:âTheâresearchâshowedâthatâ40%âofâBraziliansâfearâthatâtheyâwouldâsufferâandâstruggleâfinanciallyâifâtheyâwereâaffectedâbyâaâlong-termâillnessâorâdisability,âandâthatâtheirâfamiliesâwouldânotâhaveâanyâmeansâofâensuringâfinancialâstabilityâinâtheâfirstâyearsâfollowingâtheirâdeath.âMostâofâthoseâsurveyedâsaidâthatâthisâisâmainlyâdueâtoâaâlackâofâsufficientâsavings/investmentsâ(47%);âonlyâ18%âofâtheârespondentsâmentionedâinsufficientâinsuranceâprotection.âThisâisâanâindicationâthatâinâmanyâcasesâinsuranceâisâstillânotâconsideredâaâvalidâoptionâtoâbridgeâaâcriticalâlifeâsituation,âevenâlessâsoâinâlightâofâBrazilâsâwell-developedâcultureâofâsaving.ââSource:âSwissâRe5
â
Theâironyâofâthisâwas,âwhenâaskedâwhatâtheyâmightâpayâforâcriticalâillnessâcover*,âmanyârespondentsânamedâaâfigureâforâwhichâcoverageâalreadyâexists.âWhenâaskedâwhyâtheyâdidânotâpurchaseâcover,âmostâcitedâtheâcomplexityâofâinsurance.âThisâsuggestsâthatâinsurersâshouldâdevelopâproductsâthatâareâsimpler,âmoreâeasilyâdistributedâandâunderstandable.â
HealthcareâinâBrazil
Inâ2012,âtotalâhealthâexpenditureâstoodâatâ8.9%âofâBrazilâsâGDP;âpublicâexpenditureâaccountedâforâ46%âofâtheâtotal,âwhileâprivateâexpenditureâaccountedâforâtheâremainder.âOfâtheâprivateâexpenditure,â58%âwasâdirectlyâout-of-pocket,â40%âwasâthroughâprivateâhealthâinsuranceâandâ2%âthroughâotherâtypesâofâfinancing4.â
*â Criticalâillnessâcoverâisâanâinsuranceâproduct,âwhereâtheâinsurerâisâcontractedâtoâtypicallyâmakeââaâlumpâsumâcashâpaymentâifâtheâpolicyholderâisâdiagnosedâwithâoneâofâtheâcriticalâillnessesâlistedââinâtheâinsuranceâpolicy.
MostâBraziliansâhopeâtheirâsavingsâwouldâbeâadequateâinâcaseâofâillness.
Figureâ4:âIfâyouâwereâtoârequireâcareâandâsupportâinâlaterâlife,âinâyourâownâhomeâorâinâaâcareâhome,âhowâwouldâyouâpayâit?
ManyâBraziliansâseemâwillingâtoâpayâtheâcostâofâcriticalâillnessâcover,âbutâciteâcomplexityâofâinsuranceâasâtheâreasonâforânotâpurchasingâit.
Inâ2012,âtotalâhealthâexpenditureâstoodâatâ8.9%âofâBrazilâsâGDP.
Swiss Reâ RiskâDialogueâSeriesâ 11
TheâcurrentâhealthcareâsystemâinâBrazil,âcalledâSingleâHealthâSystem,ââSistemaâĂnicoâdeâSaĂșdeââ(SUS)âwasâcreatedâinâ1988âinâorderâtoârectifyâtheâinequalityâthatâexistedâinâhealthâassistanceâamongâtheâpopulation.âInâtheory,âpublicâhealthâassistanceâisâmandatoryâandâuniversalâforâanyâBrazilianâcitizen.âTheâSUSâisâsupposedâtoâprovideâeveryâcitizenâcomprehensiveâhealthcareâservicesâinâpublicâhealthâunitsâatâtheâcounty,âstateâandâfederalâlevels,âorâinâprivateâhealthâunitsâcontractedâbyâtheâpublicâadministration.âTheâSUSâisâfinancedâthroughâgeneralâtaxationâandâsocialâsecurityâcontributions.âDueâtoâbudgetâissues,âtheâfundingâofâSUSâisânotâsufficientâtoâprovideâqualityâhealthcareâtoâtheâentireâpopulation.
Privateâhealthâinsurance
Asâanâoptionâtoâtheâfailingsâofâtheâpublicâhealthâcareâsystem,âalmostâ50âmillionâBrazilianâcitizensâhaveâsomeâkindâofâprivateâhealthcareâcoverage,âpayingâadditionallyâforâsimilarâorâoverlappingâhealthâcoverage.âPrivateâcompaniesâthatâofferâthisâkindâofâcoverageâinâexchangeâforâaâmonthlyâpaymentâareâcalledâHealthâPlanâOperators,ââOperadorasâdeâPlanosâdeâSaĂșdeââ(OPS).âThereâareâalsoâspecialisedâhealthâinsuranceâcompaniesâofferingâprivateâhealthcareâplans.âOtherâplayersâareâmedicalâcooperatives,âself-insuranceâschemesâandânot-for-profitâplans.
Theâtotalânumbersâofâhealthâoperatorsâdecreasedâinâtheâlastâdecadeâtoâaroundâ1100;âfurtherâmarketâconsolidationâisâexpectedâdueâtoâgrowthâplansâofâdominantâmarketâplayers,âforeignâinvestment,âandâmoreârestrictiveâregulationsâaffectingâsmallerâoperations.â
HealthâinsuranceâpremiumsâareâestimatedâatâUSDâ48bn,âaâfigureâthatâhasâsteadilyâgrownâinârecentâyears,âbutâwithâconsiderableâroomâforâfurtherâgrowth.âHowever,âprofitabilityâremainsâlow,âdueâtoâaâhighâclaimsâratioâofâaroundâ80â85%â(claimsâtoâpremiums)âoverâtheâlastâ10âyears.âOnceâadministrationâandâacquisitionâcostsâareâdiscounted,âtheâcombinedâratioâisâaboutâ100%,âwhichâmeansâhealthâinsurersâareâbreakingâeven6.âThisâisâinâlargeâpartâdueâtoâmandatoryârestrictionsâwhichâcurtailâriskâselectionâ(underwriting).âTheâhighestâcostâclaimsâmadeâonâprivateâhealthâinsurersâcomeâfromâcancer,ânervousâsystemâandâcardiovascularâdiseasesâ(Figureâ5).â
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Notes:âByâfarâtheâbiggestâprivateâhealthâclaimsâariseâfromâcancerâtreatmentâ(38.4%âofâtotalâclaims;âmalesâandâfemalesâcombined).âTheâsecondâandâthirdâlargestâhealthâinsuranceâclaimsâareâfromâcardiovascularâdiseaseâinâmalesâ(5.0%),âfollowedâbyânervousâsystemâclaimsâinâfemalesâ(4.3%).ââSource:âANSâ(NationalâHealthâAgency)âandâFENSAUDEâ(AssociationâofâBrazilianâHealthâOperators)âââperiodicalâreports
Brazilâsâcurrentâhealthâsystem,ââSistemaâĂnicoâdeâSaĂșdeââ(SUS)âwasâcreatedâinâ1988âinâorderâtoârectifyâtheâinequalityâthatâexistedâinâhealthâassistanceâamongâtheâpopulation.
Almostâ50âmillionâBrazilianâcitizensâhaveâsomeâkindâofâprivateâhealthcareâcoverage,âpayingâadditionallyâforâsimilarâorâoverlappingâhealthâcoverage.
Theâtotalânumbersâofâhealthâoperatorsâdecreasedâinâtheâlastâdecade.
HealthâinsuranceâpremiumsâareâestimatedââatâUSDâ48bn.
Figureâ5:âPrivateâhealthâinsuranceâconditionsâbasedââonâtotalâclaimsâcostâ
12â Swiss Reâ RiskâDialogueâSeries
SEARCH â The search for health data and insights from Brazil
Providingâimprovedâinsuranceâproducts
WeâareâthusâleftâinâBrazilâwithâaâscenarioâwhereâmanyâcitizensâfeelâinsecureâaboutâtheâcoverâtheyâhave;âaâuniversalâhealthâsystemâthatâstrugglesâtoâprovideâhealthâforâall;âandâaâconstrainedâhealthâinsuranceâsystemâwithâlittleâroomâtoâinnovateâandâaâlackâofâincentiveâtoâcontrolâcosts.âAânumberâofâtrendsâsuggestâthatâtheseâconditionsâareâsetâtoâdeteriorate.âTheâpopulationâisâageing,âwhichâwillâincreaseâchronicâconditions.âWithâlowâbirthârates,âtheâdependencyâratioâwillâdeteriorate.âSocialâtrendsâareâinâflux,âwithâaâdeclineâofâfamilyâunitsâandâelderlyâcareâwhichâfrequentlyâaccompaniesâthem.â
Atâtheâsameâtime,âtheâgrowingâmiddleâclassâinâBrazilâhaveâbeenâfrustratedâatâtheirâinabilityâtoârealiseâtheâexpectationsâofâtheirânewâsocialâstatus.âInâ2013,âthereâwereâsignificantâmiddleâclassâriots,âmainlyâdueâtoâtheâcostâofâpublicâtransport.âHealthâmayâwellâbeâaâfutureâpoliticalâpressureâpoint,âasâpublicâhealthâservicesâstruggleâtoâofferâwhatâtheyâpromise;âandâprivateâinsurersâareârestrictedâinâtheâservicesâtheyâprovide.âTheâexcessâdemandâonâhealthâprovisionâisâinâpartâhelpingâfuelâmedicalâinflation,ârunningâatâaroundâtwiceâtheârateâofâgeneralâinflation.âIncreasingâcostsâwillâexacerbateâanâalreadyâdifficultâsituation.â
InâBrazil,âasâinâmanyâotherâmarkets,âtheâconvergenceâofâsocialâandâdemographicâtrendsâisâcreatingâanâexcitingâtimeâforâgrowthâinâhealthâinsurance.âFutureâproductsâtoâcoverâlifeâandâhealthâwillâgoâbeyondâtraditionalâofferingsâandâencompassâtheâhealthâandâsocialâcareâspectrum.âInsurersâcanâcapitaliseâonâtheseâtrends,âutilisingânewâtechnologiesâtoâhelpâcloseâsocietiesââhealthâprotectionâgaps.â
OneâpotentialâsolutionâinâBrazilâwouldâbeâtoâencourageâemployersâtoâcontributeâtoâvoluntaryâgroupâinsuranceâschemes,âsupportedâbyâtheârightâtaxâbreaksâandâincentives.âTheseâschemesâshouldâbeâonâanââoptâoutââratherâthanââoptâinââbasis.âIndividualsâwouldâhaveâtheâchanceâtoâpayâintoâinsuranceâschemesâinâearlyâadulthoodâwhenâpremiumsâareâlow.âMedicalâplansâcouldâalsoâincludeâaâsavingsâcomponent.âTheseâproductsâcouldâbeâdistributedâtogetherâwithâpublicâservicesâorâprivateâhealthâplans.â
Translatingâfrequencyâandâaverageâcostâdataâintoâknowledgeâandâcountingâwithâsolidâevidence-basedâtoolsâenableâinsurersâtoâimproveâriskâassessmentâandâriskâselectionâskillsâandâthereforeâprovideâfairâpricingâandâaffordableârates.âInsurersâcanâstabiliseâpremiumsâthroughâhigherâcustomerâretention,âsupportedâbyâknowledge-backedâunderwriting.âTheâanalysisâandâdataâprovidedâbyâtheâSEARCHâprojectâdoneâinâcollaborationâwithâtheâHarvardâSchoolâofâPublicâHealthâisâaâvaluableâtoolâinâsupportingâthisâexpansionâofâtheâinsuranceâknowledgeâbase.â
Manyâcitizensâfeelâinsecureâaboutâtheâcoverâtheyâhave;âtheâuniversalâhealthâsystemâstrugglesâtoâprovideâhealthâforâall;âandâtheâhealthâinsuranceâsystemâisâconstrainedâwithâlittleâroomâtoâinnovateâandâaâlackâofâincentiveâtoâcontrolâcosts.
Healthâmayâwellâbeâaâfutureâpoliticalâpressureâpoint,âasâpublicâhealthâservicesâstruggleâtoâofferâwhatâtheyâpromise;âandâprivateâinsurersâareârestrictedâinâtheâservicesâtheyâprovide.â
Futureâproductsâtoâcoverâlifeâandâhealthâwillâgoâbeyondâtraditionalâofferingsâandâencompassâtheâhealthâandâsocialâcareâspectrum.â
OneâpotentialâsolutionâinâBrazilâwouldâbeâtoâencourageâemployersâtoâcontributeâtoâvoluntaryâgroupâinsuranceâschemes.
Translatingâfrequencyâandâaverageâcostâdataâintoâknowledgeâandâcountingâwithâsolidâevidence-basedâtoolsâenableâinsurersâtoâimproveâriskâassessmentâandâriskâselectionâskillsâandâthereforeâprovideâfairâpricingâandâaffordableârates.
Swiss Reâ RiskâDialogueâSeriesâ 13
References1.â âJaggyâCâandâDamâWâ(2012).âAâmatterâofâfairnessâââIncreasingâtheâinsurabilityâ
ofâHIV.âRiskâDialogueâMagazine,âSwissâReâCentreâforâGlobalâDialogue;ââhttp://swissre.com/cgd.
2.â âNabholzâCâandâSomervilleâKâ(2011).âFairâRiskâAssessmentâinâLifeâ&âHealthâInsurance.âSwissâRe;âhttp://www.swissre.com.
3.â âWorldâinsuranceâinâ2012â(2013).âsigmaâNoâ3/2013,âSwissâRe;ââhttp://www.swissre.com.
4.â âOâInstitutoâdeâPesquisaâEconĂŽmicaâAplicadaâ(Ipea),âMinisterioâdaâFazenda.5.â âBrazilâCustomerâSurveyâReportâ(2013).âCapturingâfutureâopportunities.ââ
SwissâRe;âhttp://www.swissre.com.6.â âANSâ(NationalâHealthâAgency)âââCadernaâdeâinformaçãoâ2014;âFENSUADEâ
(AssociationâofâBrazilianâHealthâOperators).ââ
About the authors
Eduardo Lara di Lauro EduardoâLaraâdiâLauroâisâtheâHeadâofâHealthâInsuranceâLatinâAmericaâatâSwissâRe.âHeâisâresponsibleâforâdevelopingâandâimplementingâSwissâReâsâPrimaryâMedicalâInsuranceâstrategiesâinâLatinâAmerica,âandâhasâoverââ27âyearsâofâexperienceâinâtheâinsuranceâindustry.âPriorâtoâjoiningâSwissâRe,âheâwasâPrincipalâandâManagingâDirectorâofâaâlargeââUSâHealthcareâConsultingâPracticeâbasedâinâMexico.âHeâhasâpublishedâseveralâarticlesâandâspokeâatânumerousâforumsâonâissuesârelatedâtoâLifeâ&âHealthâinsurance,âhealthâsystemsâandâmanagedâcareâtopicsâinâMexico,âUSA,âChile,âPanama,âPeruâandâColombia.âHeâservedâasâtheâPresidentâofâtheâMexicanâAssociationââofâActuariesâandâisâaâboardâmemberâofâtheâHealthâCommitteeâofâtheâInternationalâActuarialâAssociation.âHeâisâaâCertifiedâActuaryâbyâtheâMexicanâNationalâCollegeâofâActuaries,âandâgraduatedâfromâtheâScienceâFacultyâofâMexicoâsâNationalâAutonomousâUniversityâ(UNAM).â
Rolf Steiner RolfâSteinerâisâaâSeniorâConsultantâinâLifeâ&âHealthâatâSwissâRe.âBasedâinâSaoâPaulo,âBrazil,âheâisâresponsibleâforâLifeâ&âHealthâPrimaryâValueâChainâoperationsâinâLatinâAmerica.âHeâjoinedâSwissâReâinâ1997âasâaâMarketingâActuary.âHeâbecameâtheâheadâofâtheâSwissâReâofficeâinâBuenosâAiresâinâ2002âandâwasâresponsibleâforâallâofâSwissâReâsâLifeâ&âHealthâbusinessâinâSouthâAmerica.ââInâ2005,âheâmovedâtoâRomeâtoâmanageââSwissâReâsâLifeâ&âHealthâoperationsâinâItaly.ââInâ2008,âSteinerâtookâoverâresponsibilityââforâSwissâReâsâLatinâAmericanâoperationsâcoveringâPuertoâRicoâandâGlobalâRisks.ââThenâinâ2010,âheâagainâheadedâSwissâReâsâofficeâinâSĂŁoâPaulo,âwhereâheâwasâresponsibleâforâreinsuranceâoperationsâinâBrazilâandâtheâSouthernâCone.âPriorâtoâjoiningâSwissâRe,âheâwasâaâLifeâActuaryâatâUnionâReâandâholdsâaâdegreeâinâmathematicsâfromâETHâZurich.
Swiss Reâ RiskâDialogueâSeriesâ 15
Overview of health risk factors in Brazil
Brazil has made significant progress in reducing infectious diseases, although problems still persist. Currently non-communicable diseases (NCDs) represent the largest mortality and morbidity burden in the country. This situation may become more critical as the population ages and the prevalence for being overweight and obese increases. Brazil has a historically good record of facing health challenges through large scale campaigns. It most recently became the global leader in tobacco control, despite being among the top 5 producers of tobacco in the world. This article discusses historical and current pattern of mortality, morbidity and associated risk factors in Brazil, particularly when faced with structural demographic change. It also discusses government programmes, such as the Family Health Strategy and the Strategic Action Plan to tackle NCDs.
HealthâcampaignsâinâBrazil:âAâbriefâhistory
SeveralâhistoricalâeventsârelatedâtoâpublicâhealthâinâBrazilâsinceâtheâRepublicâera,ârangingâfromâdiscoveryâofânewâdiseases,âtoânovelâcontrolâmethodsâofâmalaria,âtoâlargeâscaleâcampaigns,âplayedâanâimportantâroleâinâtheâpastâandâtoâsomeâextentâsetâtheâcontextâforâwhatâweâobserveânowâinâtheâcountry.âAnâimportantâeventâinâcreatingâaâmomentumâforâchangeâwasâaâspeechâdeliveredâbyâaâphysicianânamedâMiguelâPereiraâinâ1916âatâtheâMedicalâSchoolâinâRioâdeâJaneiro.âWhileâreferringâtoâexpeditionsâthatâassessedâtheâhealthâconditionsâofâruralâareasâinâtheâNorthâandâNortheastâregions1â6,âheâstatedâthatâruralâBrazilâwasâanâenormousâhospital7.â
Poorâhealthâconditionsâofâtheâpoorâandâruralâpopulationsâwereâseenâasâanâobstacleâtoâeconomicâdevelopment.âSanitationâmovements,âwhichâbroughtâtogetherâphysicians,âscientists,âintellectualsâandâpoliticians,âresultedâinâmajorâreformsâofâtheâsanitaryâservicesâinâtheâcountry.âImportantâmilestonesâincludedâtheâstartâofâtheâPro-SanitationâMovementâinâ1916,âasâwellâasâtheâcreationâofâtheâNationalâDepartmentâofâPublicâHealthâinâ1920âandâtheâMinistryâofâEducationâandâPublicâHealthâAffairsâinâ19308.
Largeâscaleâ(andâmostlyâvertical)âcampaignsâwereâlaunchedâtoâaddressâspecificâdiseasesâsuchâasâyellowâfever,âbubonicâplague,âsmallpoxâandâmalaria.âThisâmodelâofâinterventionâgainedââmomentum,âandâmanyâofâtheseâcampaignsâreceivedâsupportâfromâtheâRockefellerâFoundation.âThereâareâcampaignsâstillâpresentâinâBrazil,âsuchâasâtheâNationalâImmunizationâDayâagainstâPoliomyelitis8.
Demographicâtransition
CrucialâtoâtheâunderstandingâofâcurrentâhealthâriskâfactorsâinâBrazilâisâtheâdemographicâtransitionâthatâbroughtâaboutâmajorâchangesâtoâtheâstructureâofâtheâpopulation,âcoupledâwithâpatternsâofâeconomicâgrowthâandâsocialâchangesâthatâhaveâbeenâobservedâsinceâtheâmid-20thâcentury.
Brazilâexperiencedâhighâpopulationâgrowthâbetweenâ1940âandâ1960,âanâaverageâofâ2.8%âperâyear.âAfterâaâsimilarâgrowthâbetweenâ1960âandâ1970,âtheâgrowthâstartedââtoâdeclineâinâtheâ1970sâ(2.5%),âreachingâanâaverageâofâ1.64%âperâyearâduringâ1991âandâ20009,âandâ1.17%âbetweenâ2000â2010.âTheâtotalâfertilityârateâ(TFR)âremainedâatâhighâandârelativelyâconstantâlevelsâbetweenâ1940âandâ196010.âAâmodestâandââslowâdeclineâsinceâtheâearlyâ1900sâandâsmallâoscillationsâinâfertilityâinâtheâ1950sââandâ1960sâhaveâbeenâreported9,11.âNevertheless,âimportantâdemographicââtransformationsâstartedâinâtheâmid-1960s.âInâfourâdecades,âtheâTFRâexperiencedâaâdramaticâdecline:âfromâ6.3âinâ1960âtoâ2.3âinâ20009,10,12,âandâtheâ2010âPopulationâCensusâindicatedâaâTFRâofâ1.9.âThisâdeclineâoccurredâinâallâregionsâandâacrossâdifferentâsocioeconomicâgroups.
Aâseriesâofâhistoricalâeventsâincludingâaâ1916âspeechâbyâMiguelâPereira,âaâleadingâphysician,âshapedâtheâdiscourseâonâpublicâhealthâinâBrazil.
Atâoneâtime,âpoorâhealthâconditionsâwereâseenâasâanâobstacleâtoâeconomicâdevelopment.
Campaignsâwereâlaunchedâtoâcombatâspecificâdiseasesâsuchâasâyellowâfever,âbubonicâplague,âsmallpoxâandâmalaria.
DemographicâchangesâinâBrazilâhaveâhadâanâimpactâonâcurrentâhealthâriskâfactors.
Brazilâsâpopulationâgrewârapidlyâbetweenâ1940âandâ1970.âHowever,âtheâtotalâfertilityârateâfromâdroppedâfromâ6.3âinâ1960âtoâ1.9ââinâ2010.
MarciaâC.âCastroâ
16â Swiss Reâ RiskâDialogueâSeries
Overview of health risk factors in Brazil
Regardingâmortality,âinâtheâ1940sâlifeâexpectancyâinâBrazilâwasâbelowâ50âyears13.ââByâ2012,âtheânumberâincreasedâtoâ74.6â(71âforâmalesâandâ78.3âforâfemales)14.ââMostâofâtheâgainsâinâlifeâexpectancyâwereâaâdirectâresultâofâtheâdeclineâinâinfantâmortalityâ(IMR)15.âBrazilâhadâanâIMRâofâ162âperâ1000âliveâbirthsâinâ1930;âbetweenâ1930âandâ1970,âIMRâdeclinedâbyâ29.2%,âandâbetweenâ1970âandâ2005,âitâfellâ79.7%16.âAccordingâtoâtheâ2010âPopulationâCensus,âIMRâwasâ15.6.
Asâaâresultâofâtheseâchangesâinâmortalityâandâfertility,âtheâageâstructureâofâtheâpopulationâbecameâolder.âInâ1950,âtheâmedianâageâofâtheâpopulationâwasâ18,âwithâ41.8%âofâtheâpopulationâconcentratedâinâagesâyoungerâthanâ15,âandâ4.3%âagedââ60âorâolder.âInâ2010,âtheâmedianâageâincreasedâtoâ27,âwithâ24.1%âofâtheâpopulationâyoungerâthanâ15,âandâ10.8%âagedâ60âorâolder.âInâtheâwealthiestâregionsâofâtheâcountryâ(SoutheastâandâSouth),âtheâmedianâageâofâtheâpopulationâisâevenâhigherââatâ3217.
Inâaddition,âitâisâworthâhighlightingâthat:â(i)âtheâpopulationâbecameâmoreâurbanised:âfromâ36.2%âinâ1950âtoâ84.4%âinâ2010;âandâ(ii)âtheâpopulationâhadâbetterâaccessâtoâinfrastructure.âAccessâtoâelectricityâincreasedâfromâ68.5%âinâ1980âtoâ99.5%âinâ2012;â25.8%âofâtheâpopulationâhadâaccessâtoâsanitationâinâ1980âandâ97.4%âhadâaccessâinâ2012.âInâ1980,â47.5%âhadâaccessâtoâpipedâwater,âwhileâinâ2012âthisâfigureâincreasedâtoâ84.3%.
Nationalâincomeâincreasedâbetweenâtheâ1960sâandâ1990sâmoreâthanâ3âtimes,âaccompaniedâbyâanâaugmentationâofâsocialâdisparities18.âBrazilâbecameâoneâofâtheâmostâunequalâcountriesâworldwideâââitârankedâ2ndâinâincomeâconcentrationâinâ199819,âandâinâ1999,âitâwasâtheâcountryâwithâtheâhighestâratioâbetweenâtheâaverageâincomeâofâtheâ20%ârichestâandâtheâ20%âpoorest,âaboveâ3020.
Sinceâ2001,âaâsteadyâdeclineâinâinequalityâhasâbeenâobserved,âwithâtheâGiniâIndexâdecreasingâfromâ57.1âinâ2001âtoâ50.5âinâ2012â21,22.âThisâdeclineâwasâobservedâinâ80%âofâBrazilianâmunicipalities.
Epidemiologicalâtransition
TheâpatternâofâdiseaseâburdenâinâBrazilâhasâalsoâbeenâchanging,âparticularlyâsinceâtheâ1950s.âTheâproportionâofâtotalâdeathsâdueâtoâinfectiousâdiseasesâdecreasedâfromâalmostâ50%âinâ1930âtoâaboutâ5%âinâ200723,24.âInâcontrast,âinâ2007âapproximatelyâ72%âofâallâdeathsâwereâattributableâtoânon-communicableâdiseasesâ(NCDs)âincludingâcardiovascularâdiseasesâ(theâmainâcauseâofâdeath),âchronicârespiratoryâdiseases,âdiabetes,âcancer,âandâothers,âincludingârenalâdiseases25.
Regardingâinfectiousâdiseases,âBrazilâobservedâimportantâsuccesses/partialâsuccesses,âandâsomeâfailures.âAmongâtheâsuccessesâare:âtheâcontrolâofâvaccine-preventableâdiseases,âtheâreductionâinâmortalityâbyâdiarrhea,âandâtheâcontrolâofâChagasâdisease.âPartialâsuccessesâincludeâtheâcontrolâofâleprosy,âschistosomiasis,âmalaria,âhepatitis,âHIV/AIDSâandâtuberculosis.âAmongâtheâfailuresâareâtheâcontrolâofâdengueâandâvisceralâleishmaniasis23.
MortalityâandâmorbidityâforâNCDsâareâgreatestâamongâtheâpoor.âAge-standardisedâmortalityâdueâtoâNCDsâregisteredâaâ20%âdeclineâbetweenâ1996âandâ2007,âmostlyâforâcardiovascularâandâchronicârespiratoryâdiseases26.âTheâdeclineâwasâassociatedâwithâreductionsâinâsmokingâandâexpansionâofâprimaryâhealthâcare.âIndeed,âstandardisedâmortalityâratesâforâcardiovascularâdiseaseâdecreasedâfromâ287.3âperâ100â000âpeopleâinâ1980âtoâ161.9âinâ2003â(theâdiseaseâwithâtheâlargestâdeclineâinâtheâsameâperiodâwasâstroke:âfromâ95.2âtoâ52.6âperâ100â000âpeople26).âHowever,âdiabetesâandâhypertensionâareâincreasing,âasâisâtheâprevalenceâofâoverweightâandâobesityâinââtheâpopulation25.
Lifeâexpectancyâhasâsteadilyâincreasedâsinceâ1940âandâbyâ2012âwasâ74.6âforâmalesâandâ78.3âforâfemales.
Dueâtoâchangesâinâmortalityâandâfertility,âtheâmedianâageâofâtheâpopulationâhasâincreased.
Brazilâsâpopulationâhasâbecomeâmoreâurbanisedâsinceâ1950âandânowâhasâbetterâaccessâtoâinfrastructure.
Nationalâincomeâhasârisenâsinceâtheâ1960s;âhowever,âeconomicâinequalityâalsoâincreased.
Sinceâ2001,âeconomicâinequalityââhasâimproved.
Diseaseâburdenâhasâchanged.âByâ2007,ânearlyâ75%âofâdeathsâwereâattributableâtoânon-communicableâdiseases.
Infectiousâdiseasesâareâinâdecline,âalthoughâtheâcontrolâofâdengueâandâvisceralâleishmaniasisâisâstillâaâchallenge.
Mortalityâdueâtoâcardiovascularâandâchronicârespiratoryâdiseasesâisâonâtheâdecline,âbutâdiabetesâandâhypertensionâhaveâincreased.
Swiss Reâ RiskâDialogueâSeriesâ 17
â
Source:âCastroâMC,âSimĂ”esâCCS.âSpatio-temporalâtrendsâinâinfantâmortalityâinâBrazil.ââPopulationâAssociationâofâAmerica,â2010âAnnualâMeeting,âDallas,âTX.â2010:248
Currentâsituationâregardingâriskâfactorsâ
Inâ2006,âtheâBrazilianâMinistryâofâHealthâestablishedâtheâannualâTelephone-basedâSurveillanceâofâRiskâandâProtectiveâFactorsâforâChronicâDiseasesâ(VIGITEL),âcomprisingâstateâcapitalsâandâtheâFederalâDistrictâ(aboutâ54â000âinterviewsâaâyear).ââItâallowsâtheâanalysisâofâriskâandâprotectiveâfactorsâofâNCDsâfoundâinâtheâadultâpopulationâ(agedâ18âyearsâorâolder)27.
Brazilâhasâmadeâimportantâprogressâtowardsâreducingâsmoking:âtheâprevalenceâofâsmokingâinâ2011âwasâ14.8%,âaâmajorâdeclineâfromâ34.8%âinâ1989â(asâreportedâbyâtheâNationalâSurveyâonâHealthâandâNutritionâ(PNSN))25,28,29.âThisâwasâachievedâthroughâseveralâpreventativeâlegalâactionsâbeganâinâ1996â(egâtaxâincreases,âuseâofâpictureâwarningsâonâcigaretteâpacks,âandâbans/restrictionsâonâadvertising)30.
WhileâaâlongâtimeâseriesâonâphysicalâactivityâinâBrazilâisânotâavailable,âdataâfromâVIGITELâshowsâthatâaboutâ15%âofâtheâadultâpopulationâengagedâinâatâleastâ30âminutesâofâsomeâtypeâofâphysicalâactivityâforâatâleastâfiveâdaysâaâweekâinâ2010,âwithâtheâmostâactiveâbeingâyoungâandâwellâeducatedâmales.âAboutâ14%âwereâinactive,âandâ28.2%âreportedâwatchingâthreeâhoursâorâmoreâofâtelevisionâaâday31.
TheânutritionalâtransitionâinâBrazilâisâofâcrucialâimportanceâandâoneâofâtheâgreatestâchallengesâahead18:âwhileâtheâprevalenceâofâchildâstuntingâdeclined,âtheâprevalenceâofâoverweightâandâobesityâhasâsignificantlyâandâsteadilyâincreasedâinâtheârecentâpast32,33.âInâ2011,âtheâoverweightâincidenceâamongâadultsâwasâ48.5%â(52%âamongâmenâandâ45%âamongâwomen);âinâ1974â75,âtheâoverweightâincidenceâwasâ18.6%âamongâmales34,35.âTheâprevalenceâofâobesityâhasâincreasedâfromâ11.4%âinâ2006âtoâ15.8%âinâ2011.âThisâisâalsoâaâconcernâamongâchildrenâagedâ5â9:âinâ2008â9,â33.5%âandâ14.3%âofâtheseâchildrenâwereâoverweightâandâobese,ârespectively36.
Figureâ1:âTemporalâtrendsâofâsomeâfactors
Sinceâ2006,âtheâBrazilianâMinistryâofâHealthâhasâconductedâtelephoneâbasedâsurveysâtoâmonitorâriskâfactorsâofânon-communicableâdiseases.
Smokingâhasâdecreasedâsignificantlyââamongâtheâpopulationâdueâtoâpreventativeâlegalâactions.
Aboutâ15%âofâadultsâinâBrazilâengageâinâatâleastâ30âminutesâofâphysicalâactivityâfiveâtimesâperâweek.
Inârecentâyears,âmoreâandâmoreâBraziliansâhaveâbecomeâoverweightâorâobese.
Under-nutrition (children under 5)*
Vaccination**
Breastfeeding (children 0â4 months)***
Antenatal care (7 or more visits)**
Womenâs education (8 or more years)
Womenâs education (less than 4 years)
Access to sanitation
Access to electricity
Access to piped water
Urbanisation
0% 20% 40% 60% 80% 100%
2005 1980
18â Swiss Reâ RiskâDialogueâSeries
Overview of health risk factors in Brazil
Theâdistributionâofâriskâandâprotectiveâfactorsâisânotâequalâamongâsocialâgroups.âSmoking,âconsumptionâofâmeatâwithâvisibleâfat,âandâobesityâareâmoreâcommonâamongâtheâless-educated,âwhileâphysicalâactivityâduringâleisureâtimeâandâtheârecommendedâconsumptionâofâfruitsâandâvegetablesâ(fiveâportionsâaâday,âfiveâorâmoreâtimesâaâweek)âareâhigherâamongâtheâpopulationâwithâ12âorâmoreâyearsâofâschooling.âInâaddition,âtheâhighestâincreaseâinâtheâprevalenceâofâbeingâoverweightâwasâobservedâinâtheâNorthâandâNortheastâregionsâ(theâpoorest),âwhileâtheâincreaseâinâtheâprevalenceâofâobesityâwasâhigherâinâtheâSouthâandâSoutheastâ(theâwealthiest)29.
Discussion
Brazilâhasâgoneâthroughâmajorâdemographic,âeconomicâandâsocialâchanges,âandâtheâepidemiologicalâtransitionâisâstillâongoing.âWhileâmajorâachievementsâonâtheâhealthâarenaâhaveâbeenâobserved,âimportantâchallengesâremain.âRegardingâNCDs,âforâexample,âtheânumberâofâdeathsâdueâtoâcardiovascularâdiseaseâhasâincreasedâsinceâ1980,âmainlyâaâresultâofâtheâchangesâinâtheâageâstructureâofâtheâpopulationâthatâisâbecomingâolderâ(andâthusâmoreâelderlyâareâexposedâtoâtheâriskâofâchronicâdiseases)26.âTheâstandardisedâmortalityârates,âhowever,âhaveâbeenâdeclining,âmainlyâaâreflectionâofâdeclinesâinâsmokingâandâimprovedâaccessâtoâbasicâhealthâcare25.
Regardingâaccessâtoâhealthâcare,âtheâFamilyâHealthâProgram,âimplementedâinâ1994,âaimsâtoâimproveâaccessâtoâprimaryâhealthâcare,âutilisingâaâcommunity-basedâapproachâforâlocalâcareâprovision.âHealthâcareâservicesâareâprovidedâbyâaâteamâcomprisedâofâatâleastâoneâphysician,âoneânurse,âoneânurseâassistant,âandâupâtoâsixâcommunityâhealthâworkers;âsomeâteamsâmayâalsoâincludeâaâdentistâandâtwoâassistants.âEachâteamâisâresponsibleâtoâprovideâcareâforâupâtoâ1000âfamiliesâ(orâapproximatelyâ4500âpeople)âinâaâdeterminedâgeographicalâarea37.âAsâofâDecemberâ2013,â64.7%âofâtheâpopulationâwasâreachedâbyâcommunityâhealthâagents,âandâ56.4%âcoveredâbyâfamilyâhealthâteamsâ(withâmarkedâregionalâdifferences).
Currently,âoneâofâtheâmostâpressingâchallengesâregardingâNDCsâisâtheâsignificantâandâsteadyâincreaseâinâtheâoverweightâandâobeseâpopulationâ(children,âadolescentsâandâadults).âToâaddressâthatâchallengeâandâothers,âinâ2011âtheâBrazilianâMinistryâofâHealthâlaunchedâtheâStrategicâActionâPlanâtoâtackleâNCDsâinâtheâcountry.âTheâPlanâaimsâatâpreparingâBrazilâtoâcopeâwithâandârestrainâNCDsâinâtheânextâ10âyears.âItâaddressesâfourâmainâgroupsâofâdiseasesâ(cardiovascular,âcancer,âchronicârespiratory,âandâdiabetes)âandâtheirâsharedâmodifiableâriskâfactorsâ(smoking,âalcoholâabuse,âphysicalâinactivity,âunhealthyâdiet,âandâobesity).âItâdescribesâguidelinesâandâmeasuresâtoâbeâtakenâconcerning:âa)âsurveillance,âinformation,âevaluation,âandâmonitoring;âb)âhealthâpromotion;âandâc)âcomprehensiveâcare29.â
Theâsuggestedânationalâgoalsâofâtheâprogrammeâareâto:âreduceâprematureâmortalityârateâ(<â70âyearsâold)âcausedâbyâNCDsâatâ2%âaâyear;âreduceâprevalenceâofâobesityâamongâchildren;âreduceâprevalenceâofâobesityâamongâadolescents;ârestrainâobesityâamongâadults;âreduceâprevalenceâofâalcoholâabuse;âincreaseâleisureâtimeâphysicalâactivityâlevels;âincreaseâfruitâandâvegetableâconsumption;âreduceâtheâaverageâsaltâconsumption;âreduceâprevalenceâofâsmoking;âincreaseâcoverageâforâmammogramsâexamsâamongâ50âtoâ69-year-oldâwomen;âincreaseâcoverageâforâcervicalâcancerâpreventiveâexamsâamongâ25âtoâ64-year-oldâwomen;âandâtreatâ100%âofâwomenâdiagnosedâwithâprecursoryâlesionsâofâcancer.
Inâsummary,âBrazilâhasâmadeâsignificantâprogressâinâreducingâinfectiousâdiseases,âalthoughâproblemsâstillâpersist.âNCDsâcurrentlyârepresentâtheâlargestâmortalityâandâmorbidityâburdenâinâtheâcountry,âwhichâcanâbecomeâmoreâcriticalâconsideringâtheâageingâpopulationâandâtheâincreasingânumberâofâoverweightâandâobeseâindividuals.âTheâsuccessfulâimplementationâofâtheâStrategicâActionâPlanâtoâtackleâNCDsâ(describedâabove)âwillâbeâcrucialâinâtheâyearsâtoâcome.âHistorically,âBrazilâhasâshownââaâgoodârecordâofâfacingâhealthâchallenges,âandâmostârecentlyâbecameâtheâworldâleaderâinâtobaccoâcontrol,âdespiteâbeingâamongâtheâtopâ5âproducersâofâtobaccoâinââtheâworld30,38.âTheâfutureâisâyetâtoâbeâwritten.
Theâdistributionâofâriskâfactorsâdiffersâbyâsocialâgroup;âsmoking,âconsumptionâofâhighâfatâmeatâandâobesityâareâmoreâcommonâamongâtheâlessâeducated.
Althoughâmajorâachievementsâinâhealthâhaveâbeenâobserved,âsomeâchallengesâremain.
BrazilâimplementedâtheâFamilyâHealthâProgramâinâ1994âtoâimproveâaccessâtoâprimaryâhealthâcare.
Toâaddressâtheâsteadyâincreaseâinâtheânumberâofâoverweightâandâobeseâindividualsâandâtoâcopeâwithâtheâriseâinânon-communicableâdiseases,âtheâMinistryâofâHealthâlaunchedâtheâStrategicâActionâPlan.
Theâprogrammeâalsoâstressesâtheâimportanceâofâphysicalâactivityâandâincreasedâfruitâandâvegetableâconsumption.ââ
Brazilâcontinuesâtoâmakeâsignificantâprogressâinâreducingâinfectiousâdiseases,âbutâisâstillâlookingâtoâreduceânon-communicableâdiseases.
Swiss Reâ RiskâDialogueâSeriesâ 19
References1.â âThomasâHWâ(1910).âTheâsanitaryâconditionsâandâdiseasesâprevailingâinâ
Manaos,ânorthâBrazil,â1905â1909,âwithâplanâofâManaosâandâchart.âExpeditionâtoâtheâAmazon,â1905â1909.âRockefellerâArchiveâCenter.âCasaâdeâOswaldoâCruzâ(FIOCRUZ)âcollection.âDOC.007.
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PonteâCF,âFalleirosâI,âeditors.âNaâcordaâbambaâdeâsombrinha:âaâsaĂșdeânoâfioâdaâhistĂłria.âRioâdeâJaneiro:âFundaçãoâOswaldoâCruzâ(Fiocruz).â73-110.
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11.â âFriasâLA,âCarvalhoâJAMâ(1994).âFecundidadeânasâregiĂ”esâbrasileirasâaâpartirâdeâ1903:âumaâtentativaâdeâreconstruçãoâdoâpassadoâatravĂ©sâdasâgeraçÔes;âCaxambĂș,âMG.âAssociaçãoâBrasileiraâdeâEstudosâPopulacionais.â23-46.
12.â âCarvalhoâJAMdâ(2004).âCrescimentoâpopulacionalâeâestruturaâdemogrĂĄficaânoâBrasil.âBeloâHorizonte:âUFMG/Cedeplar.â18.
13.â âIBGEâ(2010).âObservaçÔesâsobreâaâevoluçãoâdaâmortalidadeânoâBrasil:âoâpassado,âoâpresenteâeâperspectivas.âRioâdeâJaneiro:âInstitutoâBrasileiroâdeâGeografiaâeâEstatĂsticaâââIBGE.
14.â âIBGEâ(2013).âTĂĄbuasâCompletasâdeâMortalidadeâ2012.ââhttp://wwwibgegovbr/âhome/estatistica/populacao/tabuadevida/â2012/defaultshtm.
15.â âCastroâMCâ(2001).âChangesâinâmortalityâandâlifeâexpectancy:âsomeâmethodologicalâissues.âMathematicalâPopulationâStudiesâ9:181-208.
16.â âCastroâMC,âSimĂ”esâCCSâ(2010).âSpatio-temporalâtrendsâinâinfantâmortalityâinâBrazil;âDallas,âTX.
17.â âVasconcelosâAMN,âGomesâMMFâ(2012).âTransiçãoâdemogrĂĄfica:âaâexperiĂȘnciaâbrasileira.âEpidemiolâServâSaĂșdeâ21:539-548.
18.â âMonteiroâCAâ(2000).âTheâepidemiologicâtransitionâinâBrazil.âIn:âPAHO,âeditor.âObesityâandâPoverty:âAâNewâPublicâHealthâChallenge.âWashington,âD.C:ââPanâAmericanâHealthâOrganization.â67-76.
19.â âWorldâBankâ(1999).âWorldâDevelopmentâIndicatorsâ1998/99.âWashington,âDC:âWorldâBank.
20.â âBarrosâRP,âHenriquesâR,âMendonçaâRâ(2000).âDesigualdadeâeâpobrezaânoâBrasil:âretratoâdeâumaâestabilidadeâinaceitĂĄvel.âRevistaâBrasileiraâdeâCiĂȘnciasâSociaisâ15:123-142.
21.â âArbixâGâ(2007).âAâquedaârecenteâdaâdesigualdadeânoâBrasil.âRevistaâBrasileiraâdeâCiĂȘnciasâSociaisâ22:132-139.
22.â âRochaâSâ(2012).âOâDeclĂnioâSustentadoâdaâDesigualdadeâdeâRendaânoâBrasilâ(1997â2009).âRevistaâEconomiaâ13:629-645.â
23.â âBarretoâML,âTeixeiraâMG,âBastosâFI,âXimenesâRAA,âBarataâRB,âetâalâ(2011).âSuccessesâandâfailuresâinâtheâcontrolâofâinfectiousâdiseasesâinâBrazil:âsocialâandâenvironmentalâcontext,âpolicies,âinterventions,âandâresearchâneeds.âLancetâ377:1877-1889.
24.â âAraĂșjoâJDdâ(2012).âPolarizaçãoâepidemiolĂłgicaânoâBrasil.âEpidemiolâServâSaĂșdeâ21:533-538.
20â Swiss Reâ RiskâDialogueâSeries
Overview of health risk factors in Brazil
About the author
Marcia C. CastroMarciaâCastroâisâAssociateâProfessorâofâDemographyâinâtheâDepartmentâofâGlobalâHealthâandâPopulationâatâtheâHarvardâSchoolâofâPublicâHealth,âandâAssociateâFacultyâofâtheâHarvardâUniversityâCenterâforâtheâEnvironment.âTheâcoreâofâherâresearchâfocusesâonâtheâdevelopmentâandâuseâofâmultidisciplinaryâapproaches,âcombiningâdataâfromâdifferentâsourcesâtoâidentifyâtheâdeterminantsâofâmalariaâtransmissionâinâdifferentâecologicalâsettings,âprovidingâevidenceâforâtheâimprovementâofâcurrentâcontrolâpolicies,âasâwellâasâtheâdevelopmentâofânewâones.
25.â âSchmidtâMI,âDuncanâBB,âSilvaâGAe,âMenezesâAM,âMonteiroâCA,âetâalâ(2011).âChronicânon-communicableâdiseasesâinâBrazil:âburdenâandâcurrentâchallenges.âLancetâ377:1949-1961.
26.â âCurioniâC,âCunhaâCB,âVerasâRP,âAndrĂ©âCâ(2009).âTheâdeclineâinâmortalityâfromâcirculatoryâdiseasesâinâBrazil.âRevâPanamâSaludâPublicaâ25:9-15.
27.â âBrasil.âMinistĂ©rioâdaâSaĂșdeâ(2007)âVigitelâBrasilâ2006:âvigilĂąnciaâdeâfatoresâdeâriscoâeâproteçãoâparaâdoençasâcrĂŽnicasâporâinquĂ©ritoâtelefĂŽnico.âIn:âSaĂșdeâMd,âeditor.âBrasĂliaâSecretariaâdeâVigilĂąnciaâemâSaĂșde.âSecretariaâdeâGestĂŁoâEstratĂ©gicaâeâParticipativa.â(SĂ©rieâG.âEstatĂsticaâeâInformaçãoâemâSaĂșde).â297.
28.â âMonteiroâCA,âCavalcanteâTM,âMouraâEC,âClaroâRM,âSzwarcwaldâCLâ(2007).âPopulation-basedâevidenceâofâaâstrongâdeclineâinâtheâprevalenceâofâsmokersâinâBrazilâ(1989â2003).âBullâWorldâHealthâOrganâ85:527-534.
29.â âBrazil.âMinistryâofâHealthâ(2011).âStrategicâactionâplanâtoâtackleânoncommunicableâdiseasesâ(NCD)âinâBrazilâ2011â2022.âMinistryâofâHealth.âHealthâSurveillanceâSecretariat.âHealthâSituationâAnalysisâDepartment.ââ(SeriesâB.âBasicâHealthâTexts).â160.
30.â âSzkloâAS,âAlmeidaâLMd,âFigueiredoâVC,âAutranâM,âMaltaâD,âetâalâ(2012).âAâsnapshotâofâtheâstrikingâdecreaseâinâcigaretteâsmokingâprevalenceâinâBrazilâbetweenâ1989âandâ2008.âPreventiveâMedicineâ54:162-167.
31.â âBrasil.âMinistĂ©rioâdaâSaĂșdeâ(2011).âVigitelâBrasilâ2010:âvigilĂąnciaâdeâfatoresâdeâriscoâeâproteçãoâparaâdoençasâcrĂŽnicasâporâinquĂ©ritoâtelefĂŽnico.âBrasĂlia:âSecretariaâdeâVigilĂąnciaâemâSaĂșde.âSecretariaâdeâGestĂŁoâEstratĂ©gicaâeâParticipativa.âMinistĂ©rioâdaâSaĂșde.
32.â âVictoraâCG,âAquinoâEML,âLealâMdC,âMonteiroâCA,âBarrosâFC,âetâalâ(2011).âMaternalâandâchildâhealthâinâBrazil:âprogressâandâchallenges.âLancetâ377:â1863-1876.
33.â âCarlosâAM,âWolneyâLC,âBarryâMPâ(2004).âTheâBurdenâofâDiseaseâfromâUndernutritionâandâOvernutritionâinâCountriesâUndergoingâRapidâNutritionâTransition:âaâViewâFromâBrazil.âAmericanâJournalâofâPublicâHealthâ94:ââ433-434.
34.â âIBGEâ(1975).âEstudoâNacionalâdaâDespesaâFamiliarâ(Endef)â1974â1975.âInstitutoâBrasileiroâdeâGeografiaâeâEstatĂstica.â
35.â âBrasil.âMinistĂ©rioâdaâSaĂșdeâ(2012).âVigitelâBrasilâ2011:âvigilĂąnciaâdeâfatoresâdeâriscoâeâproteçãoâparaâdoençasâcrĂŽnicasâporâinquĂ©ritoâtelefĂŽnico.âBrasĂlia:âSecretariaâdeâVigilĂąnciaâemâSaĂșde.âSecretariaâdeâGestĂŁoâEstratĂ©gicaâeâParticipativa.âMinistĂ©rioâdaâSaĂșde.
36.â âIBGEâ(2010).âPesquisaâdeâOrçamentosâFamiliaresâ(POF)â2008â2009.âAntropometriaâeâestadoânutricionalâdeâcrianças,âadolescentesâeâadultosânoâBrasil.âRioâdeâJaneiro:âInstitutoâBrasileiroâdeâGeografiaâeâEstatĂstica.
37.â âMinistĂ©rioâdaâSaĂșdeâ(2009).âSaĂșdeâdaâFamĂlia.âBrasĂlia,âDF:ââMinistĂ©rioâdaâSaĂșde.âhttp://dtr2004.saude.gov.br/dab/index.âphpââ(AccessedâinâAugustâ2009).
38.ââMonteiroâCA,âCavalcanteâTM,âMouraâEC,âClaroâRM,âSzwarcwaldâCLâ(2007).âPopulation-basedâevidenceâofâaâstrongâdeclineâinâtheâprevalenceâofâsmokersâinâBrazilâ(1989â2003).âBulletinâofâtheâWorldâHealthâOrganization.â86:527-534.
Swiss Reâ RiskâDialogueâSeriesâ 21
Risk factors for cardiovascular disease in Brazil: Time trends and current status
As in other emerging economies, chronic conditions such as cardiovascular disease (CVD) and diabetes have emerged as the major causes of mortality in Brazil, accounting for 37% of deaths in the country. Although there has been a considerable reduction of smoking and physical inactivity, the epidemiological transition in Brazil is marked by trends toward unhealthy diet patterns and a poor cardio-metabolic profile. This is characterised by increased consumption of processed foods, as well as a higher prevalence of overweight individuals, obesity, impaired fasting glucose and diabetes, potentially reversing the decline in CVD mortality in the medium-to long-term.
Brazilâhasârecentlyâexperiencedâpoliticalâandâeconomicâchangesâthatâhaveâgreatlyâinfluencedâitsâdemography,âsocialâstructureâandâlifestyle.âAsâmortalityâandâfertilityâratesâdecreasedâoverâtheâpastâ40âyears,âlifeâexpectancyâinâBrazilâhasâincreasedâfromâ52âtoâ73âyearsâofâage;âtheâproportionâofâpeopleâlivingâinâurbanâsettingsâhasâincreasedâfromâ55%âtoâ80%;âandâtheâpercentageâofâBraziliansâwithâhigherâeducationâ(â„10âyearsâofâformalâschooling)âhasânearlyâdoubled1.â
TheâmodernâBrazilianâpopulationâisâpredominantlyânon-white,âolderâandâhasâaâgreaterâproportionâofâmiddleâclassâinhabitantsâcomparedâtoâ19702.âAsâinâotherâemergingâeconomies,âchronicâconditionsâsuchâcardiovascularâdiseaseâ(CVD)âandâdiabetesâhaveâemergedâasâtheâmajorâcausesâofâmortalityâinâBrazil,âaccountingâforâ37%âofâdeathsâinâtheâcountry3,4.âImprovementsâinâhealthâcareâqualityâandâaccessâoverâtheâpastâtwoâdecadesâhaveâsuccessfullyâcontributedâtoâtheâreductionâofâCVDâmortality1;âhowever,âcurrentâtrendsâinâlifestyleâandâmetabolicâriskâfactorsâshowâaâshiftâtowardâunhealthyâdietaryâpatternsâandâpoorâmetabolicâhealth.âThisâmayâreverseâtheâdeclineâinâCVDâmortalityâinâtheâmediumâtoâlong-term.âUnderstandingâtimeâtrendsâandâtheâcurrentâstatusâofâmodifiableâriskâfactorsârelevantâtoâcardiometabolicâhealthâmayâprovideârelevantâinformationâtoâinformâstrategiesâfocusedâonâdiseaseâpreventionâinâBrazil.
Dietaryâfactors
IncreasingâincomeâandâtheâavailabilityâofâhighlyâprocessedâfoodsâinâBrazil,âamongâotherâfactors,âhaveâinfluencedâtheâdietaryâpatternsâinâtheâcountry,âparticularlyâinâurbanâenvironments.âBetweenâ1999âandâ2009,âtheâhouseholdâincomeâperâcapitaâinâBrazilâincreasedâbyâ25%2,5,âwhichâparalleledâanâincreaseâinâdiningâout6.âBetweenâ1974âandâ2009,âthereâwasâaâ15%âdecreaseâinâenergyâintakeâfromârice,âandâaâ33%âdecreaseâinâenergyâfromâbeans,âtwoâofâtheâmajorâtraditionalâfoodâstaplesâinâtheâcountry7â9â(Figureâ1).âSimilarly,âaâconsiderableâdecreaseâinâmeanâenergyâintakeâfromâvegetablesâ(27%)âandâfishâ(20%)âwereâobservedâduringâtheâsameâperiod.âThereâwas,âhowever,âaâsubstantialâincreaseâinâenergyâintakeâfromâlessâhealthyâfoodsâsuchâasâprocessedâmeatâ(102%)âandâready-to-eatâmealsâ(250%)â(Figureâ1).â
Brazilâsârecentâpoliticalâandâeconomicâchangesâhaveâhadâanâimpactâonâdemography,âsocialâstructureâandâlifestyle.
Theâpopulationâisâmostlyânon-white,âolderâandâmiddleâclass.âCardiovascularâdiseaseâandâdiabetesâareâtheâmajorâcausesâofâmortality.
Risingâincomeâandâtheâavailabilityâofâhighlyâprocessedâfoodsâhaveâinfluencedâdietaryâpatterns.
MarciaâC.âdeâOliveiraâOtto
22â Swiss Reâ RiskâDialogueâSeries
Risk factors for cardiovascular disease in Brazil: Time trends and current status
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2008â20092002â20031995â19961987â19881974â1975
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Sources:âLevi-Costaâetâalâ(2005);âLevyâetâalâ(2012)
âDataâfromâtheâsameâstudyâsuggestsâthatâdietâpatternsâdifferâaccordingâtoâincomeâlevels.âAsâpurchasingâpowerâincreases,âBraziliansâtendâtoâconsumeâlessârice,âbeansâandâfish,âandâmoreâredâmeat,âprocessedâmeatâandâready-to-eatâmeals8.âHigherâincomeâlevelsâwereâalsoâassociatedâwithâhigherâconsumptionâofâvegetables,âfruitâandâfruitâjuices,âdairyâproductsâandâalcohol8â(Figureâ2).âOverall,âtimeâtrendsâandâanalysisâbyâincomeâlevelsâareâconsistentâwithâaâtransitionâtoâlowerâconsumptionâofâtraditionalâBraziliansâfoodsâandâhigherâconsumptionâofâindustrialisedâfoods,âasâwellâasâincreasedâconsumptionâofâvegetablesâandâfruitsâamongâBraziliansâinâhigherâincomeâstrata.ââ
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Source:âLevi-Costaâ(2005)
Figureâ1:ââEnergyâintakeâfromâdifferentâfoodsâinâBrazil,â1974â2009â
Asâincomeâincreases,âBraziliansâtendâtoâconsumeâlessârice,âbeansâandâfishâandâmoreâprocessedâmeatâandâready-to-eatâmeals.
Figureâ2:ââEnergyâintakeâfromâselectedâfoodsâbyâincomeâlevelsâinâBrazilâ(2002â2003)
Swiss Reâ RiskâDialogueâSeriesâ 23
Highâbody-massâindexâandâobesityâ
Consistentâwithâaâworldwideâtrend,âtheâprevalenceâofâoverweightâandâobeseâindividualsâhasâincreasedâconsiderablyâinâBrazilâinârecentâdecades.âResultsâfromâsurveysâusingâanthropometricâmeasurementsâinâaânationallyârepresentativeâsampleâshowedâanâoverâtwofoldâincreaseâinâtheâprevalenceâofâoverweightâindividualsâ(fromâ18.5%âtoâ50.1%)âandâaâfourfoldâincreaseâinâtheâprevalenceâofâobesityâ(2.8%âinâ1975âtoâ12.4%âinâ2008)âamongâadultâmenâbetweenâ1975âandâ2008.âDuringâtheâsameâperiod,âtheâprevalenceâofâoverweightâinâadultâBrazilianâwomenâincreasedâfromâ28.7%âtoâ48%,âwhileâtheâprevalenceâofâobesityâinâwomenâdoubled6,10.âAâstudyâevaluatingâincome-specificâtrendsâreportedâthatâchangesâinâtheâprevalenceâofâobesityâinâBrazilâbetweenâ1975âandâ1989âwereâ66%âhigherâinâmenâinâtheâlowerâquintileâofâfamilyâincome,âcomparedâtoâthoseâinâtheâhighestâquintile8.ââ
Consistentâwithâtheâchangesâobservedâinâadults,âoneâthirdâofâBrazilianâchildrenâbetweenâ5-9âyearsâofâageâwereâoverweightâinâ2008,âwhileâ17%âofâboysâandâ12%âgirlsâwereâconsideredâobese10â(Figureâ3).âExcessiveâadiposityâisâhigherâinâchildrenâlivingâinâurbanâareas,âasâwellâasâinâtheâsoutheast,âtheâregionâwithâtheâhighestâpopulationâdensityâinâtheâcountry.âOnâtheâotherâhand,âbetweenâ1974âandâ2009,âchildhoodâunderânutrition,âassessedâasâlowâheightâforâage,âdecreasedâfromâ29%âtoâ7%âinâboysâandâfromâ27%âtoâ6%âamongâgirlsâ5â9âyearsâofâage6,10.
0%
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20%
25%
30%
35%
Obese
Overweight2008â20091974â1975 2008â20091974â1975
Boys Girls
Source:âMeloâetâalâ(2010)
Surveysâshowâthatâmenâandâwomenâhaveâbecomeâincreasinglyâoverweightâorâobeseâsinceâ1975.âMenâwithâlowerâincomesâareâdisproportionatelyâmoreâobese.
Moreâandâmoreâchildrenâareâeitherâoverweightâorâobese.
Figureâ3:ââPrevalenceâofâoverweightâandâobesityâamongâBrazilianâchildrenâ5â9âyearsâofâageâ1974â2009
24â Swiss Reâ RiskâDialogueâSeries
Risk factors for cardiovascular disease in Brazil: Time trends and current status
Dyslipidemiaâ
VeryâfewâstudiesâhaveâreportedâlipidâlevelsâinâtheâBrazilianâpopulation.âAccordingâtoââaârecentâreportâfromâtheâWorldâHealthâOrganization,âtheâprevalenceâofâhighââtotalâcholesterolâlevelsâ(â„5.28âmmol/L)âamongâBrazilianâadultsâinâ2008âwasâapproximatelyâ43%,âwithânoâmajorâdifferencesâbetweenâmenâandâwomen11.âDataâfromâ1980âtoâ2008âshowedânoâmajorâchangesâinâtheâmeanâtotalâcholesterolâlevelsâoverâtheâyears,âwhichâsuggestsâthatârecentâimprovementsâinâhealthâcareâhaveânotâaffectedâhypercholesteromiaâlevelsâinâtheâcountry11.âInâaâstudyâwhichâincludedâoverâ1500âchildrenâ7â14âyearsâofâageâlivingâinâtheâlargeâcityâofâCampinas,âtheâprevalenceâofâhighâtotalâcholesterolâwasâ11%âamongâgirlsâandâ8%âamongâboys.âComparedâtoâboys,âgirlsâhadâhigherâmeanâtriglyceridesâandâaâtotal:HDL-Câratio12,âwhichâisâaâpredictorâofâcardiovascularâdiseaseâriskâinâadultâpopulations.
Highâfastingâglucoseâandâdiabetesâ
Inâaâmulti-centreâstudyâconductedâinâ1988,âwhichâincludedâoverâ20â000âparticipantsâagedâ30â69âlivingâinâ9âlargeâcitiesâinâBrazil,âtheâprevalenceâofâeachâtypeâIIâdiabetesâandâimpairedâglucoseâtoleranceâwasâapproximatelyâ8%13.âNearlyâ46%âofâdiabetesâcasesâhadânotâbeenâdiagnosedâbefore,âandâ23%âofâpreviouslyâdiagnosedâcasesâwereâuntreated.âTheâstudyâshowedânoâmajorâdifferencesâinâage-adjustedâdiabetesâprevalenceâacrossâsex,âraceâorâsocial-economicâstatusâcategories13.âTwoâcross-sectionalâstudies,âwhichâincludedâparticipantsâofâsimilarâages,âhaveâsubsequentlyâbeenâconductedâinâtwoâlargeâcitiesâlocatedâinâtheâstateâofâSaoâPaulo.âInâ1997,âinâRibeiraoâPreto,âtheâprevalenceâofâdiabetesâandâimpairedâfastingâwasâ12%âandâ8%ârespectively14.âAâstudyâconductedâinâSaoâCarlosâinâ2007âreportedâ13.5%âofâparticipantsâhavingâdiabetesâandâ5%âhavingâimpairedâfastingâglucoseâlevels15.ââTheâprevalenceâofâmetabolicâdisordersâamongâobeseâparticipantsâinâRibeiraoâPretoâwasâoverâtwoâtimesâgreaterâcomparedâtoâtheânon-obeseâparticipants.âInâaddition,ââtheâproportionâofâundiagnosedâdiabetesâwasâ60%âgreaterâinâobeseâparticipantsâcomparedâtoânon-obeseâadults14.âTheâlackâofârecentânationalâdataâonâmetabolicâriskâfactorsâincludingâbloodâlipidsâandâfastingâplasmaâglucoseâlevelâbyâsex,âageâandâgeographicâlocationâisâaâmajorâlimitationâtoâtheâunderstandingâofâtheâpotentialâimpactâtheseâvariablesâhaveâonâcardio-metabolicâmortalityâandâmorbidity.
Hypertensionâ
Timeâandâregionalâtrendsâonâhypertensionâ(bloodâpressureâ>140/90âmmHg)âinâBrazilâwereârecentlyâreportedâinâaâsystematicâreviewâincludingâdataâfromâoverâ120â000âparticipantsâinâcross-sectionalâandâcohortâstudies16.âCombiningâdataâfromâstudiesâpublishedâinâdifferentâdecades,âinvestigatorsâestimatedâtheâprevalenceâofâhypertensionâasâ36%âinâtheâ1980s,â33%âinâtheâ1990sâandâ29%âinâtheâ2000s16.âAlthoughâtheâauthorsâsuggestedâaâtrendâtowardâaâlowerâprevalenceâofâhypertensionâinâBrazil,âthereâareâlimitationsâtoâtheâgeneralisationâofâearlyâestimatesâthatâmightâpreventâsuchâaâstraightforwardâconclusion.âInâfact,âresultsâfromâaâsurveyâincludingâadultsâlivingâinâ27âBrazilianâstateâcapitalsâreportedâaâ3%âincreaseâinâtheâprevalenceâofâself-reportedâhypertensionâbetweenâ2006âandâ2009âamongâmenâandâwomen17,18.âTheâhighâprevalenceâofâhypertensionâinâBrazilâandâitsâpotentialâimpactâonâcardiovascularâhealthâsuggestsâtheâneedâforâappropriateâmeasuresâtoâreduceâtheâprevalenceâofâthisâimportantâCVDâriskâfactorâinâtheâcountry.
DataâonâlipidâlevelsâinâBrazilâisâlimited.âThereâareâindications,âhowever,âthatâimprovementsâinâhealthâcareâhaveânotâhadâaâmajorâimpactâonâcholesterolâlevels.â
Inânineâlargeâcities,âtheâprevalenceâofâeachâtypeâIIâdiabetesâandâimpairedâglucoseâtoleranceâwasâapproximatelyâ8%.â
Theâprevalenceâofâhypertensionâwasâ36%âinâtheâ1980s,â33%âinâtheâ1990sâandâ29%âinâtheâ2000s.
Swiss Reâ RiskâDialogueâSeriesâ 25
Smokingâandâphysicalâactivityâ
Brazilâwasâoneâofâtheâfirstâcountriesâtoâimplementânationalâanti-tobaccoâpolicies.âPricingâpoliciesâimplementedâbetweenâ1991âandâ1993âledâtoâaânearlyâ80%âincreaseâinâtheâpriceâofâtobaccoâproducts,âandâaâsubsequentâ20%âreductionâinâtobaccoâuse.ââAâstudyâusingânationalâhouseholdâsurveyâdataâreportedâage-adjustedâsmokingâprevalenceâdecreasedâfromâ35%âinâ198919âtoâ12.1%âinâ201220.âInâaddition,âtheâaverageâdailyânumberâofâcigarettesâconsumedâbyâadultsâinâBrazilâdecreasedâfromâ13.3âtoâ11.619.âTheâreductionâinâcigaretteâsmokingâconsumptionâwasâsimilarâacrossâsex,âlivingâconditionsâ(urbanâvsârural),âeducationâandâincomeâlevels,âwhichâsuggestsââaâsignificantâimpactâofâanti-tobaccoâpoliciesâacrossâdifferentâstrataâofâsociety.
Althoughâthereâhasâbeenâaâconsiderableâreductionâinâwork-relatedâphysicalâactivityâdueâtoâtheâuseâofâmodernâtechnologyâinâtheâworkâplace21,âdataâfromâcross-sectionalâsurveysâinâ27âstateâcapitalsâshowedâaâriseâinâphysicalâactivityâinâtheâcountry.âInâ2012,â35%âofâBraziliansâmetâtheâWHOâguidelinesâforâphysicalâactivityâ(â„150âmin/weekâofâmoderateâtoâvigorousâactivity),âanâalmostâtwofoldâincreaseâcomparedâtoâtheâestimatesâinâ2006.âCross-sectionalâsurveys,âincludingâoverâ2000âadultsâlivingâinâSaoâPauloâcity,âshowedâanâincreasedâprevalenceâofâpeopleâmeetingâWHOâguidelinesâforâphysicalâactivityâfromâ16%âinâ2002âtoâ61.5â%âinâ200822.ââ
Improvementsâinâphysicalâactivityâlevelsâwereâsimilarâamongâmenâandâwomen,âandâinterestingly,âtheâgreatestâchangeâwasâobservedâamongâthoseâinâlowâincomeâcategories22.âAccordingâtoâtheâauthors,âchangesâinâphysicalâactivityâlevelsâwereâlargelyâinfluencedâbyâtheâimplementationâofââAgitaâBrasilâ,âaânationalâprogrammeâtoâpromoteâphysicalâactivityâinâ1997.âOverall,âimprovementsâinânationalâsmokingâprevalenceâandâphysicalâactivityâlevelsâinâlargeâcitiesâfollowingâimplementationâofâhealthâpoliciesâsupportâtheâimportantâroleâofâpopulationâstrategiesâtoâchangeâbehaviour.
Conclusion
Althoughâthereâhasâbeenâaâconsiderableâreductionâinâsmokingâandâphysicalâinactivity,âtheâepidemiologicalâtransitionâinâBrazilâisâmarkedâbyâtrendsâtowardâunhealthyâdietâpatternsâandâaâpoorâcardiometabolicâprofile.âThisâisâcharacterisedâbyâincreasedâconsumptionâofâprocessedâfoods,âasâwellâasâaâhigherâprevalenceâofâoverweightâindividuals,âobesity,âimpairedâfastingâglucoseâandâdiabetes.âConsistentâwithâsuboptimalâlifestyleâandâhealthâcareâmanagement,ârecentâdataâshowsâthatâ29%âofâBrazilianâadultsâhaveâhypertensionâandâ43%âhaveâhypercholesteromia.âInâ2011,âtheâBrazilianâMinistryâofâHealthâlaunchedâaânationalâplanâtoâreduceâtheâincidenceâofânon-communicableâchronicâdiseases,âwithâaâfocusâonâphysicalâactivity,âtobaccoâcontrol,âfoodâguidanceâandâpolicy,âtreatmentâofâdiabetesâandâhypertension,âcancerâscreening,âandâoverallâaccessâtoâhealthâcare23.âIncreasingâengagementâofâotherâsegmentsâofâtheâBrazilianâsocietyâsuchâasâtheâmedia,âtheâfoodâindustry,âtheâserviceâsectorâandâeducationâareânecessaryâtoâtheâlongâtermâsuccessâofâthisâstrategy.âInâaddition,âtheâdevelopmentâofâepidemiologicâstudiesâprospectivelyâassessingârelevantâriskâfactorsâandâtheirâimpactâonâhealthâinâdifferentâgroups,âincludingâunderservedâpopulations,âisâessentialâtoâmeasureâtheâeffectivenessâofâthisâinitiative,âasâwellâasâtoâhelpâdesignâspecificâinterventionsâforâtheâpreventionâofâcardio-metabolicâdiseaseâinâBrazil.
Anti-tobaccoâpoliciesâsuchâasâraisingâtheâpriceâofâtobaccoâhaveâreducedâtobaccoâuse.
Betweenâ2006âandâ2012,âtheâpercentageâofâBraziliansâwhoâmetâtheâWHOâguidelinesâforâphysicalâactivityâdoubled.
Improvementsâinâphysicalâactivityâlevelsâwereâsimilarâamongâmenâandâwomen.
Evenâthoughâsmokingâdecreasedâandâphysicalâactivityâincreased,âconcernsâaboutâdietaryâpatterns,âobesityâandâdiabetesâremain.
26â Swiss Reâ RiskâDialogueâSeries
About the author
Marcia C. de Oliveira OttoMarciaâOttoâisâanâAssistantâProfessorâatâtheâUniversityâofâTexasâSchoolâofâPublicâHealthâinâHouston.âSheâreceivedâherâMSâinâenvironmentalâscienceâfromâtheâUniversityâofâSaoâPaulo,âBrazil.âSheâcompletedâherâPhDâatâtheâUniversityâofâTexasâSchoolâofâPublicâHealthâwithâaâfocusâonâmicronutrientâintakesâandâtheirârelationshipsâwithâinflammationâandâcardiovascularâdisease,âmetabolicâsyndromeâandâtypeâIIâdiabetesâinâUSâadults.âHerâcurrentâresearchâprojectsâincludeâevaluatingâtheâeffectsâofâcirculatingâfattyâacidsâonâcardiovascularâdiseaseâincidenceâandâprogression,âtheâdevelopmentâofânovelâmetricsâtoâcharacteriseâdietaryâdiversityâandâqualityâandâtheirârelationâtoâcardiovascularâandâmetabolicâdiseaseâriskâinâaâmulti-ethnicâpopulation,âandâtheâimpactâofâdietaryâandâmetabolicâriskâfactorsâonâtheâburdenâofâchronicâdiseasesâinâBrazil.
Risk factors for cardiovascular disease in Brazil: Time trends and current status
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377(9779):1778-97.2.â âInstitutoâBrasileiroâdeâGeografiaâeâEstatisticaâ(IBGE).âPesquisaâNacionalâporâAmostraâdeâ
DomicĂliosâ(2011).â01/27/14;âAvailableâfrom:âhttp://www.ibge.gov.br/home/estatistica/pesquisas/pesquisa_resultados.php?id_pesquisa=40.
3.â âPAHOâ(2012).âHealthâinâtheâAmericas.âCountryâVolume,âinâScientificâandâTechnicalâPublicationâNo.6362012,âPanâAmericanâHealthâOrganization.
4.â âSchmidtâMIâetâalâ(2011).âChronicânon-communicableâdiseasesâinâBrazil:âburdenâandâcurrentâchallenges.âLancet.â377(9781):1949-61.
5.â âBaenaâCPâetâalâ(2013).âIschaemicâheartâdiseaseâdeathsâinâBrazil:âcurrentâtrends,âregionalâdisparitiesâandâfutureâprojections.âHeart.â99(18):1359-64.
6.â âInstitutoâBrasileiroâdeâGeografiaâeâEstatisticaâ(IBGE)â(2011).âPesquisaâdeâOrcamentosâFamiliaresâ2008-2009,âIBGE:âRioâdeâJaneiro.
7.â âLevy-CostaâRBâetâalâ(â2005).â[HouseholdâfoodâavailabilityâinâBrazil:âdistributionâandâtrendsâ(1974â2003)].âRevâSaudeâPublica,â39(4):530-40.
8.â âMonteiroâCA,âCondeâWLâandâPopkinâBMâ(2007).âIncome-specificâtrendsâinâobesityâinâBrazil:â1975â2003.âAmâJâPublicâHealth.â97(10):1808-12.
9.â âLevyâRBâetâalâ(2012).âRegionalâandâsocioeconomicâdistributionâofâhouseholdâfoodâavailabilityâinâBrazil,âinâ2008-2009.âRevâSaudeâPublica.â46(1):6-15.
10.â âMeloâMEâ(2009).âOsâNĂșmerosâdaâObesidadeânoâBrasil:âVIGITELâ2009âeâPOFâ2008â2009,â2010.
11.â âWorldâHealthâOrganizationâ(2011).âNCDâCountryâProfiles:âGeneva,âSwitzerland.12.â âMouraâEC,âCastroâCMâ(2000).âPerfilâlipĂdicoâemâescolaresâdeâCampinas,âSP,âBrasil.âRevistaâ
deâSaudeâPublica,â34(5):499-05.13.â âMalerbiâDAâandâFrancoâLJâ(1992).âMulticenterâstudyâofâtheâprevalenceâofâdiabetesâ
mellitusâandâimpairedâglucoseâtoleranceâinâtheâurbanâBrazilianâpopulationâagedâ30â69âyr.âTheâBrazilianâCooperativeâGroupâonâtheâStudyâofâDiabetesâPrevalence.âDiabetesâcare.â15(11):1509-16.
14.â âTorquatoâMTâetâalâ(2003).âPrevalenceâofâdiabetesâmellitusâandâimpairedâglucoseâtoleranceâinâtheâurbanâpopulationâagedâ30â69âyearsâinâRibeiraoâPretoâ(SaoâPaulo),âBrazil.âSaoâPauloâMedâJ.â121(6):224-30.
15.â âBosiâPLâetâalâ(2009).â[Prevalenceâofâdiabetesâandâimpairedâglucoseâtoleranceâinâtheâurbanâpopulationâofâ30âtoâ79âyearsâofâtheâcityâofâSaoâCarlos,âSaoâPaulo].âArqâBrasâEndocrinolâMetabol.â53(6):726-32.
16.â âPiconâRVâetâalâ(2012).âTrendsâinâprevalenceâofâhypertensionâinâBrazil:âaâsystematicâreviewâwithâmeta-analysis.âPLoSâOne.â7(10):e48255.
17.â âMinistĂ©rioâdaâSaĂșdeâBrasilâ(2007).âVIGITELâBrasilâ2006.âVigilanciaâdeâfatoresâdeâriscoâeâprotecaoâparaâdoencasâcronicasâporâinqueritoâtelefonico.âBrasilia.
18.â âMinistĂ©rioâdaâSaĂșdeâBrasilâ(2010).âVIGITELâBrasilâ2009â-âVigilanciaâdeâfatoresâdeâriscoâeâprotecaoâparaâdoencasâcronicasâporâinqueritoâtelefonico.âMinisterioâdaâSaude:âBrasilia.
19.â âMonteiroâCAâetâalâ(2007).âPopulation-basedâevidenceâofâaâstrongâdeclineâinâtheâprevalenceâofâsmokersâinâBrazilâ(1989â2003).âBullâWorldâHealthâOrgan.â85(7):527-34.
20.â âMinistĂ©rioâdaâSaĂșdeâBrasilâ(2013).âVIGITELâBRASILâ2012.âMinisterioâdaâSaude:âBrasilia.21.â âSartorelliâDSâandâFrancoâLJâ(2003).â[TrendsâinâdiabetesâmellitusâinâBrazil:âtheâroleâofâtheâ
nutritionalâtransition].âCadâSaudeâPublica.19âSupplâ1:S29-36.22.â âMatsudoâVKâetâalâ(2010).âTimeâtrendsâinâphysicalâactivityâinâtheâstateâofâSaoâPaulo,ââ
Brazil:â2002â2008.âMedâSciâSportsâExerc.â42(12):2231-6.23.â âMinistĂ©rioâdaâSaĂșdeâBrasilâ(2011).âPlanoâdeâaçÔesâestratĂ©gicasâparaâoâenfrentamentoââ
dasâdoençasâcrĂŽnicasânĂŁoâtransmissĂveisâ(DCNT)ânoâBrasilâ2011â2022â/,âM.d.S.S.d.V.e.âSaĂșde.âEditor.
Swiss Reâ RiskâDialogueâSeriesâ 29
Two decades of research linking air pollution to cardiovascular disease in Brazil: A systematic review
Scientific evidence collected over the past twenty years suggests that the Brazilian population experiences increased adverse cardiovascular outcomes from exposure to air pollution. The strongest evidence exists for particulate matter pollution (specifically, particles with a diameter less than 10 ”m); particles have been found to be associated with increased numbers of cardiovascular mortality, cardiovascular hospital admissions and stroke. Higher levels of sulphur dioxide, a gaseous air pollutant, have also been found to be associated with increased numbers of cardiovascular-related mortality and hospital admissions among the Brazilian population.
Introduction
Cardiovascular-relatedâmorbidityâandâmortalityâareâmajorâpublicâhealthâproblemsâinâBrazil.âIschemicâheartâdiseaseâandâcerebrovascularâdiseaseârankâasâtheâ2ndâandâ3rdâleadingâcausesâofâyearsâofâlifeâlostâinâBrazil,âjustâafterâinterpersonalâviolence.âTheseâcardiovascular-relatedâdiseasesâwereâestimatedâtoâhaveâshortenedâlivesâbyâalmostâ5.3âmillionâyearsâamongâtheâBrazilianâpopulationâinâ2010.âHypertensiveâheartâdiseaseâandâotherâdisordersâofâtheâcardiovascularâandâcirculatoryâsystemsâwereâestimatedâtoâhaveâcontributedâtoâanâadditionalâ1âmillionâyearsâofâlifeâlost.1
Brazilâisâhomeâtoâtwoâmegacitiesâââoftenâdefinedâasâmetropolitanâareasâwithâmoreâthanâ10âmillionâinhabitants2âââSĂŁoâPaulo,âwithâ19.9âmillionâinhabitants,âandâRioâdeâJaneiro,âwithâ12âmillionâinhabitantsâinâ20113.âMegacitiesâareâresponsibleâforâproducingâlargeâamountsâofâpollution,âandâareâalsoâcapableâofâaffectingâregionalâandâglobalâclimateâchange2.âAsâcentresâofâeconomicâgrowth,âeducation,âandâtechnology,âlargeâcitiesâareâalsoâwhereâeffectiveâpollutionâcontrolâstrategiesâcouldâyieldâmaximumâbenefits4.
OutdoorâairâpollutionâinâSĂŁoâPauloâisâlargelyâaâconsequenceâofâemissionsâfromâvehicles.âInâ2011,âoverâ7âmillionâmotorâvehiclesâwereâinâoperationâinâSĂŁoâPaulo;ââcarâownershipâisâhighâ(aboutâ1âcarâperâtwoâinhabitants).âStrongâcommercialâandâindustrialâactivityâmeansâmanyâtrucksâoperateâinâtheâcity,âandâtrucksâandâbusesâareâgenerallyâoldâandârunâonâlow-techâenginesâthatâemitâhighâlevelsâofâpollutants5,6.ââThisâdensityâofâcars,âtrucksâandâbuses,âcombinedâwithâtheâcityâsâclimateâandâhighâelevationâ(750âmâaboveâseaâlevel),âmakesâSĂŁoâPauloâproneâtoâelevatedâpollutantâconcentrations,âparticularlyâduringâwinter.âPollutantsâcanâbecomeâtrappedâbyâlowâdispersionâconditionsâandâpersistâforâseveralâdays2,7.
Ischemicâheartâdiseaseâandâcerebrovascularâdiseaseârankâasâtheâ2ndâandâ3rdâleadingâcausesâofâyearsâofâlifeâlostâinâBrazil.â
BrazilâsâmegacitiesâââSĂŁoâPauloâandââRioâdeâJaneiroâââproduceâlargeâamountsââofâpollution.
TheânumberâofâvehiclesâinâSaoâPaulo,âcombinedâwithâitsâclimateâandâelevation,âpromotesâhighâairâpollutionâlevelsâinâtheâcity.â
JenniferâLâNguyen,âDouglasâWâDockery
30â Swiss Reâ RiskâDialogueâSeries
Two decades of research linking air pollution to cardiovascular disease in Brazil: A systematic review
Thisâarticleâdescribesâtheâscientificâevidenceâthatâhasâaccumulatedâoverâtheâlastâtwoâdecadesâ(1993âtoâ2013)âlinkingâadverseâcardiovascularâhealthâeffectsâtoâairâpollutionâexposureâinâtheâBrazilianâpopulationâ(Tableâ1).âWeâconductedâaâsystematicâreviewâusingâtwoâdatabasesâââPubMedâandâWebâofâScienceâââofâallârelevantâpopulation-basedâobservationalâââieâepidemiologicalâstudiesâonâthisâtopic,âpublishedâinâtheââpeer-reviewedâEnglishâorâPortugeseâscientificâliterature.âFigureâ1âdisplaysâtheâcitiesâincludedâinâthisâsystematicâreview.â
Brazil
Itaberai (1)
Santo Andre (1)Rio de Janeiro (2)
Porto Alegre (1)
Sao Paulo (city: 8, state: 5)Sao Jose dos Campos (3)
Source:âauthor
ThisâarticleâsummarisesâscientificâevidenceâlinkingâcardiovascularâhealthâtoâairâpollutionâinâBrazil.
Tableâ1:âAâsummaryâofâtheâstrengthâofâtheâevidenceâforâanâassociationâbetweenâairâpollutionâexposureâandâadverseâcardiovascularâoutcomesâinâBrazilâbasedâonâepidemiologicalâstudiesâconductedâbetweenâ1993âandâ2013
Figureâ1:âMapâofâcitiesâinâBrazilâwhereâstudiesâexaminingâtheâcardiovascularâhealthâeffectsâofâairâpollutionâexposureâhaveâbeenâconducted.âNumbersâinâparenthesesâindicateâhowâmanyâstudiesâfocusedâonâthatâarea.âSeveralâstudiesâinvolvedâmultipleâcities.
Particulate Air Pollutants Gaseous Pollutants
Particulate matter <2.5 ”m in diameter (PM2.5)
Particulate matter <10 ”m in diameter (PM10)
Total suspended particulates
Sulphur dioxide
Carbon monoxide
Nitrogen dioxide
Ozone
Cardiovascularâmortality 4 0 5 7 0 6
Hospitalâadmissions 4 7 4 7 7 6
Emergencyâroomâvisits 6 7 4 7 0
Ischemicâheartâdisease 6 6 6 0 0
Stroke 4 6 0 0
Arrhythmias 7 0 7 7 0
Heartârateâvariability 0 7 0
Bloodâpressure 6 7 7 7 0 7
Evidenceâforâanâassociationâ 4â Strongâ(consistentâacrossâseveralâstudies)â 5â Goodâ(consistentâbutâfewâstudies)â 6â Mixedâ(conflictingâreports)â 7â Limitedâ(basedâonââ€2âstudies)â 0ââ Noneâ(â€2âstudiesâreportânoâassociation)Source:âauthor
Swiss Reâ RiskâDialogueâSeriesâ 31
Airâpollutionâincreasesâcardiovascularâmortalityââ
TheâstrongestâevidenceâofâincreasedâcardiovascularâdeathsâfromâairâpollutionâinâBrazilâcomesâfromâaâlarge,âmulti-cityâstudyâofâselectedâLatinâAmericanâcities.âParticulateâmatter,âspecificallyâparticlesâwithâaâdiameterâ<â10â”mâ(PM10),âisâassociatedâwithâmoreâcardiovascularâandâcerebrovascularâmortalityâamongâinhabitantsâofâSĂŁoâPaulo,âRioâdeâJaneiroâandâPortoâAlegreâ(byâaboutâ0.5%â3%âperâ10â”g/m3âincreaseâinâPM10)7.âOneâotherâstudyâinâSĂŁoâPauloâfoundâanâassociationâwithâPM10,âbutâtheâeffectâsizeâwasâmuchâsmaller.8âThisâlargeâmulti-cityâLatinâAmericanâstudy7ââalsoâfoundâsomeâevidenceâofâanâadverseâeffectâofâozoneâonâcardiovascularâmortality,âbutâtheâeffectsâwereâmuchâweakerâthanâthatâforâPM10âandâcontradictoryâ(ieâhigherâozoneâlevelsâwereâfoundâtoâbeâprotectiveâofâcerebrovascularâdeathsâinâRioâdeâJaneiro).âAnotherâstudyâinâSĂŁoâPauloâfoundânoâassociationâofâcardiovascularâmortalityâwithâozone8.
ThreeâstudiesâofâSO2âhaveâconsistentlyâfoundâassociationsâwithâincreasedâdeathsâfromâcardiovascularâdisease,âmyocardialâinfarctionâandâstroke8â10.
Theâlimitedâavailableâevidenceâsuggestsânoâassociationâbetweenâcardiovascularâmortalityâandânitrogenâdioxide8âandâtotalâsuspendedâparticulates11,âandâconflictingâevidenceâforâcarbonâmonoxide8,â10.
Cardiovascular-relatedâhospitalâadmissionsâincreaseâwithâhigherâairâpollutionâlevelsâ
SimilarâtoâtheâfindingâforâcardiovascularâmortalityâinâBrazil,âhigherâlevelsâofâPM10âandâsulphurâdioxideâwereâassociatedâwithâincreasedânumbersâofâcardiovascular-relatedâhospitalâadmissions.âStudiesâhaveâconsistentlyâfoundâthatâmoreâpeopleâareâhospitalisedâforâcardiovascularâcauses,âsuchâasâischemicâheartâdisease,âmyocardialâinfarction,âstrokeâandâangina,âwhenâlevelsâofâPM10
12â17âandâsulfurâdioxide12â13,â15â17âareâhigher.â
Theâepidemiologicâevidenceâisâmixedâonâassociationsâwithâozone,12â15,â17âandâonlyâoneâorâtwoâstudiesâhaveâinvestigatedâcarbonâmonoxide15,17,ânitrogenâdioxide15,17,âandâtotalâsuspendedâparticulates18âinârelationâtoâcardiovascularâhospitalâadmissions.
Airâpollutionâmightâincreaseâtheânumberâofâemergencyâroomâvisitsâ
Currently,âtheâmostâconsistentâevidenceâlinkingâairâpollutionâtoâincreasedâemergencyâroomâvisitsâamongâtheâBrazilianâpopulationâexistsâforâcarbonâmonoxide.âSeveralâstudiesâhaveâfoundâthatâhigherâcarbonâmonoxideâlevelsâareâlinkedâtoâemergencyâvisitsâforâischemicâheartâdiseaseâ(includingâmyocardialâinfarctionâandâangina),âcardiacâarrhythmiasâandâhypertension19â22.âThereâisâconflictingâevidenceâthatâPM10âlevelsâmayâbeârelatedâtoâemergencyâroomâvisits.âTwoâstudiesâreportâevidenceâofâaâpositiveâassociationâ20,23,whileâtwoâothersâdoânot19,21.Thereâisâconsistentâevidenceâofânoâassociationâwithâozoneâacrossâseveralâstudies19â21.âTooâfewâstudiesâhaveâinvestigatedâsulphurâdioxideâandânitrogenâdioxideâatâthisâtimeâtoâmakeâaâconclusion19â21.
Sub-clinicalâeffects:âincreasedâairâpollutionâisâlinkedâtoâhigherâbloodâpressureâandâreducedâheartârateâvariabilityââ
ThereâisâsomeâevidenceâthatâhigherâairâpollutionâlevelsâareâassociatedâwithâhigherâbloodâpressureâinâtheâBrazilianâpopulation,âbutâatâthisâtime,âtheâevidenceâisâsparseâandâinconsistent.âOneâstudyâfoundâthatâhigherâlevelsâofâcarbonâmonoxideâandâsulfurâdioxideâincreasedâbloodâpressureâamongâvehicularâtrafficâcontrollersâinâSĂŁoâPaulo24,âwhileâPM10âandânitrogenâdioxideâdidânot.âHowever,âinâanotherâstudyâthatâsampledâonlyâhealthyâmaleâtrafficâcontrollers,âPM10âandâozoneâincreasedâbloodâpressure25.ââAâstudyâinvestigatingâheartârateâvariabilityâfoundâthatâhigherâsulphurâdioxideâlevelsâdecreasedâcardiacâvariability24.
Oneâstudyâfoundâthatâparticulateâmatterâcontainingâparticlesâofâaâcertainâsizeâdiameterâwereâassociatedâwithâhigherâlevelsâofâcardiovascularâandâcerebrovascularâmortality.
Studiesâthusâfarâsuggestâthereâisânoâlinkâbetweenâcardiovascularâmortalityâandânitrogenâdioxideâandâtotalâsuspendedâparticulates.
HigherâlevelsâofâPM10âandâsulphurâdioxideâhaveâbeenâassociatedâwithâincreasedânumbersâofâcardiovascular-relatedâhospitalâadmissions.
Evidenceâisâmixedâonâtheâassociationâofâozoneâwithâcardiovascularâhospitalâadmissions.
Severalâstudiesâsuggestâthatâcarbonâmonoxideâlevelsâhaveâresultedâinâincreasedâemergencyâhospitalâvisitsâforâischemicâheartâdiease,âarrhythmiasâandâhypertension.
Someâevidenceâsuggestsâthatâairâpollutionâmayâbeâlinkedâtoâhighâbloodâpressure.
32â Swiss Reâ RiskâDialogueâSeries
Two Decades of Research Linking Air Pollution to Cardiovascular Disease in Brazil: A Systematic Review
WhyâisâBrazilâaâparticularlyâinterestingâlocationâtoâstudyâairâpollution?â
Brazilâisâtheâonlyâcountryâinâtheâworldâthatâextensivelyâusesâethanol.âEthanolâisâaârenewableâfuelâmadeâfromâplantâmaterials.âUnlikeâotherânationsâwhereâairâpollutionââisâmostlyâfromâpetroleumâorânaturalâgas-basedâfuels,âairâqualityâinâBrazilâisâstronglyâdeterminedâbyâethanol-derivedâemissions.âInâ2005,â70%âofâtheâlightâdutyâvehiclesâsoldâinâBrazilâhadâflex-fuelâ(ieâdual-fuel)âenginesâthatâcanârunâonâanyâmixâofâethanolâandâgasoline7.âEthanol,âsometimesâcalledâtheââgreenâfuelâ,âisâthoughtâtoâbeâaâcleanerâalternativeâtoâgasoline.âButâtheâpictureâisânotâquiteâsoâclear.âEthanolâfuelsâincreaseâatmosphericâconcentrationsâofâsubstancesâcalledâacetaldehydeâandânitrogenâoxides,âwhichâareâsignificantâcontributorsâtoâphotochemicalâairâpollutionâandâozoneâformation.â
Aârecentâstudyâshowedâthatâozoneâlevelsâdroppedâwhenâgasolineâuseâincreasedâ(relativeâtoâethanolâuse)âinâSĂŁoâPaulo,âbutâconcentrationsâofâotherâairâpollutantsââânitricâoxideâandâcarbonâmonoxideâââincreased26.âTheseâresultsâhaveâimportantâpolicyâimplicationsâforâcountriesâlikeâtheâUSâandâotherâindustrialisedânationsâthatâareâconsideringâexpandedâuseâofâethanolâforâenergyâneeds.âInâtheâUS,âgasolineâcontainsâaboutâ10%âethanolâbyâvolume.âTheâexperienceâinâSĂŁoâPauloâmayânotâdirectlyâapplyââtoâotherâareasâhowever,âbecauseâairâpollutionâmixturesâvaryâdependingâonâtheâlocalâclimate,âvehicleâfleet,âindustrialâactivityâandâtraffic.âRegardless,âtheâexperienceâinâBrazilâdemonstratesâthatâethanolâmayânotâbeâasââgreenââasâpredicted.
Conclusion
Evidenceâfromâstudiesâconductedâbetweenâ1993â2013âsuggestsâthatâPM10âisâassociatedâwithâincreasedâcardiovascular-relatedâmortality,âhospitalâadmissionsââandâstrokeâamongâtheâBrazilianâpopulation.âOneâstudyâhasâestimatedâthatâaâ10%âreductionâinâtheâexpectedâlevelsâofâPM10âinâ2020âcouldâavoidâ11â225âdeaths,â1365âcardiovascular-relatedâhospitalâadmissions,â140â133âhospitalâvisits,âandâ2.2âmillionâdaysâofâlostâwork27.âMostâofâtheâevidenceâlinkingâairâpollutionâtoâcardiovascularâeventsâcomesâfromâstudiesâconductedâinâSĂŁoâPauloâ(cityâandâstate).âNotably,âresearchâisâlackingâonâtheâcardiovascularâhealthâeffectsâofâparticulateâmatterâlessâthanâ2.5â”mâinâdiameterâ(PM2.5).âWorldwide,âtheâstrongestâassociationsâbetweenâairâpollutionâandâcardiovascularâeventsâareâfoundâforâPM2.5.âThereâisâalsoâaâlackâofâresearchâonâhouseholdâairâpollution,âdespiteâitâbeingârecognisedâasâaâmajorâglobalâpublicâhealthâproblem28âandâtheâ12thâleadingâcontributorâtoâtheâtotalâdiseaseâburdenâinâBrazil1.âBrazilâisâanâespeciallyâinterestingâlocaleâtoâstudyâtheâhealthâeffectsâofâairâpollutionâdueâtoâitsâuniqueâpositionâasâtheâonlyânationâthatâextensivelyâusesâethanol.
Brazilâsâuseâofâethanolâmayâbeâcontributingâtoâairâpollutionâandâozoneâformation.
CountriesâsuchâasâtheâUSâthatâareâconsideringâexpandingâtheâuseâofâethanolâshouldâbeâawareâofâitsâpotentialâeffectâonâairâpollution.
Evidenceâfromâstudiesâconductedâbetweenâ1993âandâ2013âsuggestdâthatâPM10âisâhighlyâcorrelatedâwithâincreasedâcardiovascular-relatedâmortality,âhospitalâadmissionsâandâstrokeâinâBrazil.
Swiss Reâ RiskâDialogueâSeriesâ 33
References1.â âInstituteâforâHealthâMetricsâandâEvaluation.âGBDâprofile:âBrazil.ââ
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8.â âGouveiaâN,âFletcherâTâ(2000).âTimeâseriesâanalysisâofâairâpollutionâandâmortality:âeffectsâbyâcause,âageâandâsocioeconomicâstatus.âJournalâofâEpidemiologyâandâCommunityâHealth.â54(10):750-755.
9.â âAmancioâCT,âNascimentoâLFâ(2012).âAssociationâofâsulfurâdioxideâexposureâwithâcirculatoryâsystemâdeathsâinâaâmedium-sizedâcityâinâBrazil.âBrazilianâJournalâofâMedicalâandâBiologicalâResearch.â45(11):1080-1085.
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11.â âDaumasâRP,âMendonçaâGA,âPonceâdeâLeĂłnâAâ(2004).âAirâpollutionâandâmortalityâinâtheâelderlyâinâRioâdeâJaneiro:âaâtime-seriesâanalysis.âCadernosâdeâSaĂșdeâPĂșblica.â20(1):311-319.
12.â âNardocciâC,âFreitasâCU,âPonceâdeâLeonâAC,âJungerâWL,âGouveiaâNâ(2013).ââAirâpollutionâandârespiratoryâandâcardiovascularâdiseases:âaâtimeâseriesââstudyâinâCubatĂŁo,âSĂŁoâPauloâState,âBrazil.âCadernosâdeâSaĂșdeâPĂșblica.â29(9):1867-1876.
13.â âNascimentoâLF,âFranciscoâJB,âPattoâMB,âAntunesâAMâ(2012).âEnvironmentalâpollutantsâandâstroke-relatedâhospitalâadmissions.âCadernosâdeâSaĂșdeâPĂșblica.â28(7):1319-1324.â
14.â âNascimentoâLFâ(2011).âAirâpollutionâandâcardiovascularâhospitalâadmissionsâinâaâmedium-sizedâcityâinâSĂŁoâPauloâState,âBrazil.âBrazilianâJournalâofâMedicalâandâBiologicalâResearch.â44(7):720-724.
15.â âGouveiaâN,âdeâFreitasâCU,âMartinsâLC,âMarcilioâIOâ(2006).âRespiratoryâandâcardiovascularâhospitalizationsâassociatedâwithâairâpollutionâinâtheâcityâofââSĂŁoâPaulo,âBrazil.âCadernosâdeâSaĂșdeâPĂșblica.â22(12):2669-2677.
16.â âMartinsâLC,âPereiraâLA,âLinâCA,âSantosâUP,âPrioliâG,âLuizâOdoâC,âSaldivaâPH,âBragaâALâ(2006).âTheâeffectsâofâairâpollutionâonâcardiovascularâdiseases:âlagâstructures.âRevâSaudeâPublica.â40(4):677-683.â
17.â âCendonâS,âPereiraâLA,âBragaâAL,âConceiçãoâGM,âCuryâJuniorâA,âRomaldiniâH,âLopesâAC,âSaldivaâPHâ(2006).âAirâpollutionâeffectsâonâmyocardialâinfarction.âRevâSaudeâPublica.â40(3):414-419.â
18.â âArbexâMA,âSaldivaâPH,âPereiraâLA,âBragaâALâ(2010).âImpactâofâoutdoorâbiomassâairâpollutionâonâhypertensionâhospitalâadmissions.âJournalâofâEpidemiologyâandâCommunityâHealth.â64(7):573-579.â
34â Swiss Reâ RiskâDialogueâSeries
About the authors
Jennifer L. NguyenJenniferâL.âNguyen,âScD,âMPHâisâaâPost-doctoralâResearchâFellowâinâtheâDepartmentâofâEnvironmentalâHealthâatâtheâHarvardâSchoolâofâPublicâHealth.âSheâreceivedâherâMasterâofâPublicâHealthâdegreeâfromâBostonâUniversityâSchoolâofâPublicâHealthâinâ2007,âandâaâScDâinâEnvironmentalâHealthâandâEpidemiologyâfromâtheâHarvardâSchoolâofâPublicâHealthâinâ2012.âNguyenâhasâaâbroadâresearchâinterestâinâhowâenvironmentalâfactorsâaffectâcardiovascularâhealth.âSheâisâparticularlyâinterestedâinârelatingâairâpollutionâandâweatherâtoâacuteâandâchronicâcardiovascularâoutcomes.âSheâisâalsoâinterestedâinâcharacteringâindoorâandâoutdoorâthermalâenvironmentsâinâorderâtoâbetterâunderstandâhowâaâchangingâclimateâwillâimpactâhumanâhealth.
Douglas W. DockeryDouglasâW.âDockeryâisâProfessorâofâEnvironmentalâEpidemiologyâinâtheâDepartmentâofâEnvironmentalâHealthâatâtheâHarvardâSchoolâofâPublicâHealth.âHeâisâinternationallyâknownâforâhisâinnovativeâworkâinâenvironmentalâepidemiology,âparticularlyâinâunderstandingâtheârelationshipâbetweenâairâpollutionâandârespiratoryâandâcardiovascularâmortalityâandâmorbidity.âHeâwasâoneâofâtheâprincipalâinvestigatorsâofâtheâlandmarkâSixâCitiesâStudyâofâAirâPollutionâandâHealth,âwhichâshowedâthatâpeopleâlivingâinâcommunitiesâwithâhigherâfineâparticulateâairâpollutionâhadâshorterâlifeâexpectancies.âTheâInternationalâSocietyâforâEnvironmentalâEpidemiologyâhonoredâhimâwithâitsâfirstâawardâforâOutstandingâContributionsâtoâEnvironmentalâEpidemiologyâinâ1999âandâtheâfirstâBestâPaperâinâEnvironmentalâEpidemiologyâAwardâinâ2010.
Two Decades of Research Linking Air Pollution to Cardiovascular Disease in Brazil: A Systematic Review
19.â âPereiraâFilhoâMA,âPereiraâLA,âArbexâFF,âArbexâM,âConceiçãoâGM,âSantosâUP,âLopesâAC,âSaldivaâPH,âBragaâAL,âCendonâSâ(2008).âEffectâofâairâpollutionâonâdiabetesâandâcardiovascularâdiseasesâinâSĂŁoâPaulo,âBrazil.âBrazilianâJournalâofâMedicalâandâBiologicalâResearch.â41(6):526-532.
20.â âSantosâUP,âTerra-FilhoâM,âLinâCA,âPereiraâLA,âVieiraâTC,âSaldivaâPH,âBragaâALâ(2008).âCardiacâarrhythmiaâemergencyâroomâvisitsâandâenvironmentalâairâpollutionâinâSaoâPaulo,âBrazil.âJournalâofâEpidemiologyâandâCommunityâHealth.â62(3):267-272.
21.â âLinâCA,âAmadorâPereiraâLA,âdeâSouzaâConceiçãoâGM,âKishiâHS,âMilaniâRâJr,âFerreiraâBragaâAL,âNascimentoâSaldivaâPHâ(2003).âAssociationâbetweenâairâpollutionâandâischemicâcardiovascularâemergencyâroomâvisits.âEnvironmentalâResearch.â92(1):57-63.â
22.â âRumelâD,âRiedelâLF,âLatorreâMdoâR,âDuncanâBBâ(1993).âMyocardialâinfarctâandâcerebralâvascularâdisordersâassociatedâwithâhighâtemperatureâandâcarbonâmonoxideâinâaâmetropolitanâareaâofâsoutheasternâBrazil.âRevâSaudeâPublica.â27(1):15-22.
23.â âBragaâAL,âPereiraâLA,âProcĂłpioâM,âAndrĂ©âPA,âSaldivaâPHâ(2007).âAssociationâbetweenâairâpollutionâandârespiratoryâandâcardiovascularâdiseasesâinâItabira,âMinasâGeraisâState,âBrazil.âCadâSaudeâPublica.â23âSupplâ4:S570-578.
24.â âdeâPaulaâSantosâU,âBragaâAL,âGiorgiâDM,âPereiraâLA,âGrupiâCJ,âLinâCA,âBussacosâMA,âZanettaâDM,âdoâNascimentoâSaldivaâPH,âFilhoâMTâ(2005).âEffectsâofâairâpollutionâonâbloodâpressureâandâheartârateâvariability:âaâpanelâstudyâofâvehicularâtrafficâcontrollersâinâtheâcityâofâSĂŁoâPaulo,âBrazil.âEuropeanâHeartâJournal.â26(2):193-200.
25.â âChiarelliâPS,âPereiraâLAA,âSaldivaâPH,âFilhoâCF,âGarciaâML,âBragaâAL,âMartinsâLCâ(2011).âTheâassociationâbetweenâairâpollutionâandâbloodâpressureâinâtrafficâcontrollersâinâSantoâAndrĂ©,âSĂŁoâPaulo,âBrazil.âEnvironmentalâResearch.âJul;111(5):650-655.
26.â âSalvoâA,âGeigerâFMâ(2014).âReductionâinâlocalâozoneâlevelsâinâurbanâSĂŁoâPauloâdueâtoâaâshiftâfromâethanolâtoâgasolineâuse.âNatureâGeoscience.â7:450-458.
27.â âCifuentesâL,âBorja-AburtoâVH,âGouveiaâN,âThurstonâG,âDavisâDLâ(2001).âAssessingâtheâhealthâbenefitsâofâurbanâairâpollutionâreductionsâassociatedâwithâclimateâchangeâmitigationâ(2000-2020):âSantiago,âSĂŁoâPaulo,âMexicoâCity,âandâNewâYorkâCity.âEnvironmentalâHealthâPerspectives.â109âSupplâ3:419-425.
28.â âMcCrackenâJP,âWelleniusâGA,âBloomfieldâGS,âBrookâRD,âTolunayâHE,ââDockeryâDW,âRabadan-DiehlâC,âCheckleyâW,âRajagopalanâSâ(2012).âHouseholdâairâpollutionâfromâsolidâfuelâuse:âevidenceâforâlinksâtoâCVD.ââGlobalâHeart.â7:219-230.
Swiss Reâ RiskâDialogueâSeriesâ 35
Understanding the global risk of the tobacco epidemic and its trajectory in an emerging market nation
The tobacco epidemic is a âchronic global riskâ and may be the single most important risk to determine longevity and mortality in the 21st century. This report closely examines how Brazil has been confronting its tobacco problem and provides insight into the societal characteristics and external and internal influences that will determine the course of the epidemic in Brazil and other emerging market nations.
Introduction
Brazilâisâbothâtheâsecondâlargestâproducerâandâleadingâexporterâofâtobacco,âandââtheâsecondâcountryâtoâfullyâsignâtheâFrameworkâConventionâonâTobaccoâControl,âwhichâsetsâforthâmulti-sectorialâandâtrans-frontierâactionsâtoâcombatâtheâepidemicâworldwide.âBrazilâsâtobaccoâcontrolâeffortsâtoâdateâhaveâdecreasedâmaleâandâfemaleâsmokingâprevalenceâbyâ50%;âhowever,âtheâearlyâageâofâsmokingâinitiationâandârelativelyâhighâprevalenceâofâsmokingâamongâwomenâareâstillâofâmajorâconcern.âBrazilâsârecentâbanâonâtheâuseâofâmentholâandâotherâflavorsâinâtobaccoâproductsâmayâspearheadâhowâproductâregulationâdecreasesâtobaccoâuseâbyâreducingâproductâaddictiveness,âattractivenessâandâabuseâpotential.âFutureâtrendsâwillâdependâonâtobaccoâmarketingâandâpromotionâonâoneâhand,âandâpublicâhealthâpoliciesâonâtheâother,âandâtheirâinfluencesâonâtheâsocietalâacceptabilityâversusâdenormalisationâofâsmoking.â
Theâglobalâriskâofâsmoking
Theâtobaccoâepidemicâisâclearlyâaââglobalâriskââofâcatastrophicâproportionsâwithââlarge-scaleâimplicationsâforâmortalityâandâlongevityâinânations.âMeetingâtheâWorldâEconomicâForumâsâdefinitionâofâaâglobalârisk,âtheâtobaccoâproblemâisâglobalâinâscope,âhasâeconomicâimpact,âcross-industryârelevance,ârequiresâaâmulti-stakeholderâapproach,âandâisâassociatedâwithâuncertainty1.âTobaccoâwasâresponsibleâforâanâestimatedâ110âmillionâdeathsâworldwideâduringâtheâtwentiethâcenturyâandâ500âbillionâdollarsâinâyearlyâlossesâdueâtoâillnesses,âdecreasedâproductivity,âandâprematureâdeaths2.âItsâfutureâtrajectoryâdependsâonâmanyâcompetingâvariablesâandâthusâentailsâconsiderableâuncertainty.âBecauseâtheâharmsâofâtobaccoâuseâandâtheâbenefitsâofâcessationâareâwell-established,âitâisâtheâsingleâmostâpreventableâcauseâofâdeathâworldwide.âHowever,âifâcurrentâtrendsâcontinue,âtobaccoâuseâwillâgrowâandâresultâinâapproximatelyâoneâbillionâdeathsâfromâdiseasesâduringâtheâ21stâcentury2.âInâcontrastâtoâacuteâorââevent-drivenââglobalârisks,âtobaccoâuseâisâaââchronicâârisk1âwhoseâfutureâcourseâwillâbeâdeterminedâbyâprivateâandâpublicâsectorâactivitiesâandâdevelopmentsâatâtheâglobal,ânationalâandâlocalâcommunityâlevels.âUncertaintiesâregardingâitsâfutureâcourseâmayâbeâdiminishedâwithâinsightfulâanalysesâbasedâonâaâclearâunderstandingââofâitsânature,âknowledgeâofâtheâfactorsâthatâeitherâpromoteâorâmitigateâtobaccoâuseâinânations,âandâtheâwisdomâofâexperience.
Brazilâisâtheâworldâsâsecondâlargestâproducerâandâleadingâexporterâofâtobacco.
Tobaccoâwasâresponsibleâforâanâestimatedâ110âmillionâdeathsâworldwideâduringâtheâtwentiethâcenturyâandâUSDâ500âbillionâinâyearlyâlossesâdueâtoâillnesses,âdecreasedâproductivityâandâprematureâdeaths.
HillelâR.âAlpertâ
36â Swiss Reâ RiskâDialogueâSeries
Understanding the global risk of the tobacco epidemic and its trajectory in an emerging market nation
Theânatureâofâtheâtobaccoâepidemic
Anâestimatedâ1.2âbillionâpersonsâinâtheâworldâcurrentlyâsmoke,âwhileânearlyâ80%âofâtobacco-attributableâdeathsâoccurâinâlowâandâmiddle-incomeâcountries3.âInâorderâtoâanticipateâorâpredictâtheâcourseâofâtheâepidemicâinânationsâorâglobally,âtobaccoâuseâmustâbeâunderstoodâasâaâsocietalâphenomenon,âwithâtheâkeyâinfluencesâonâindividualâsmokerâsâbehaviourâoccurringâatâtheâsocial,âcommunityâandâpopulationâlevels.âTheâtobaccoâindustryâhasâlongâknownâthisâandâsetâmaintainingâtheâsocialâacceptabilityâofâsmokingâasâaâstrategicâgoal4âandâformedâaâworkingâpartyâinâtheâ1970sâtoââimproveâtheâclimateâofâsocialâacceptabilityâ5.âTheâresultâhasâbeenâtheâcreationâofâsocialânormsâthatâtreatâsmokingâbehaviourâasâacceptable,âdesirableâandâsometimesâevenâexpectedâforâaâmemberâofâsociety.â
Similarly,âresearchâinâCaliforniaâandâMassachusettsâhasâdemonstratedâthatâpopulationâinterventions,âsuchâasâcleanâindoorâairâlaws,âadvertisingârestrictionsââandâcounter-marketing,âhaveâbeenâfarâmoreâsuccessfulâinâdecreasingâsmokingâprevalenceâthanâareâindividualâlevelâinterventions6â8.âPublicâhealthâexpertsâhaveânotedâthatânotwithstandingâtheâsignificantâroleâofâcessationâtherapies,âtheâuseâmedicationsâorâcognitionâtoâfightâaâlargerâgroupâbehaviourâdoesânotâappearâtoâbeâeffectiveâinâbringingâaboutâlarge-scaleâchanges,âwhereasâchangingâsocialânormsâis8.âThisâreportâcloselyâexaminesâhowâBrazilâasâanâemergingâmarketânationâhasâbeenâconfrontingâitsâtobaccoâproblemâinâorderâtoâillustrateâandâprovideâinsightâintoâtheâsocietalâcharacteristicsâasâwellâexternalâandâinternalâinfluencesâthatâmayâdetermineâtheâcourseâofâtheâepidemicâinâsimilarânationsâandâglobally.
Riskâmitigation
Collectiveâexperienceâfromâlocal,âstateâandânationalâeffortsâtoâcurbâtheâtobaccoâepidemicâledâtoâtheâfirstâinternationalâpublicâhealthâtreaty,âtheâWHOâFrameworkâConventionâonâTobaccoâControlâ(FCTC)9,âwhichâwasânegotiatedâunderâtheâauspicesâofâtheâWHOâinâ192âcountries.âTheâFCTCâsetsâforthâmulti-sectorialâandâtrans-frontierâactionsâtoâcombatâtheâepidemicâworldwide.âItâobligesâpartiesâtoâimplementâaâvarietyâofâtobaccoâcontrolâmeasures,âwhichâincludeâbothâtobaccoâproductâsupplyâandâdemandâreductionâstrategies.âEachâofâtheâstrategiesâisâintendedâtoâhaveâaâdirectâeffectâonâreducingâtobaccoâuse.âForâexample,âincreasingâcigaretteâpricingâthroughâtaxationâhasâbeenâaâhighlyâeffectiveâinterventionâinâmanyâplacesâforâreducingâtheâdemandâforâcigarettes,âespeciallyâamongâyoungâpeopleâandâpersonsâfromâlowerâincomeâbrackets.âStudiesâbyâtheâWorldâBankâandâothersâhaveâshowedâthatâincreasesâinâtaxesâandâpricesâhaveâreducedâperâcapitaâcigaretteâconsumptionâinâBrazilâandâotherânations10.âFurtherâeffectiveâmeasuresâincludeâprotectingâtheâpublicâfromâexposureâtoâtobaccoâsmoke;ârequiringâtobaccoâproductâdisclosures;âregulatingâtobaccoâproductâpackagingâandâlabelling;ârestrictingâtobaccoâadvertising,âpromotionâandâsponsorship;âregulatingâtheâcontentsâofâtobaccoâproducts;âandâadvancingâpublicâeducation,âcommunication,âtrainingâandâawarenessâprogrammes.âOverâandâbeyondâtheâeffectsâofâtheâindividualâpolicies,âtheseâmeasuresâhaveâaâcollective,âsynergisticâeffectâtoâsociallyâdenormaliseâsmoking.
SmokingâprevalenceâhasâdecreasedâinânationsâthatâhaveâadoptedâandâsuccessfullyâimplementedâtheâFCTCâtobaccoâcontrolâpolicies.âYet,âdeclinesâinâprevalenceâhaveâbeenâlimitedâasâaâresultâofâcontinuedâtobaccoâindustryâmarketingâandâpromotionâactivities,âtheâaddictiveânatureâofâtheâproduct,âandâenduringâsocialâacceptance,âevenâinânationsâwhereâsubstantialâprogressâhasâbeenâmade.âOfâtheâstrategiesâavailable,âtobaccoâproductâregulationâhasâbeenâusedârelativelyâlittleâtoâdate,âbutâcouldâpotentiallyâhaveâfar-reachingâeffectsâonâsmoking.âAlthoughâsomeânationsâhaveâsetâlimitsâonâtarâlevelsâandâbannedâtheâuseâofâmisleadingââlightsââdescriptorsâonâpackagingâandâinâadvertising,ânotâmuchâevidenceâexistsâtoâshowâsignificantâeffectsâonâsmokingâprevalenceâasâaâresultâofâtheseâmeasures.âPossibleâreasonsâareâthatâlow-tarâcigarettesâareânoâlessâharmfulâorâaddictiveâthanâotherâcigarettes,âandââlightsââdescriptorâbansâappearâtoâhaveâbeenâcircumventedâbyâsubstitutionâofâalternative,âcolor-codedâdescriptorsâthatâareârecognisedâbyâconsumers.âTheâdesignâandâcharacteristicsâofâtobaccoâproductsâcouldâbeâregulatedâinânumerousâways,âatâleastâsomeâofâwhichâcouldâhaveâsignificantâeffectsâonâuseâbyâreducingâproductâaddictivenessâandâabuseâpotential.
Anâestimatedâ1.2âbillionâpersonsâinâtheââworldâcurrentlyâsmoke,âwhileânearlyâ80%âofâtobacco-attributableâdeathsâoccurâinââlowâandâmiddle-incomeâcountries.
Interventions,âsuchâasâcleanâindoorâairâlaws,âadvertisingârestrictionsâandâcounter-marketing,âareâfarâmoreâsuccessfulâinâdecreasingâsmokingâprevalenceâthanâareâindividualâlevelâinterventions.
TheâWHOâFrameworkâConventionâonâTobaccoâControlâsetsâforthâmulti-sectorialââandâtrans-frontierâactionsâtoâcombatâtheâepidemicâworldwide.
Smokingâprevalenceâhasâdecreased,âbutâtheâtobaccoâindustryâcontinuesâtoâmarketâandâpromoteâsmoking.
Swiss Reâ RiskâDialogueâSeriesâ 37
TheâU.S.âFoodâandâDrugâAdministrationâ(FDA)âhasâbeenâauthorisedâbyâtheâFamilyâSmokingâPreventionâandâTobaccoâControlâActâ(FSPTCA)âinâ2009âtoâsetâstandardsâforâtobaccoâproductâdesign,âcontentsâandâconstituents;âincludingâbanningâtheâuseâofâmentholâandâotherâflavorsâandâadditivesâthatâaffectâtheâappeal,âattractiveness,âandâabuseâpotentialâofâproductsâparticularlyâtoâyouth,âwomenâandâotherâpotentiallyâsusceptibleâpersons;âasâwellâasâtoâsetâotherâproductâregulations11.âTheâFSPTCAâprovidesâaâpopulation-basedâsetâofâcriteriaâforâtheâFDAâtoâuseâinâdeterminingâwhetherâaâtobaccoâproductâorâdesignâfeatureâisââappropriateâforâtheâprotectionâofâtheâpublicâhealthâ.âTheseâincludeâanâassessmentâofâtheââincreasedâorâdecreasedâlikelihoodâthatâexistingâusersâofâtobaccoâproductsâwillâstopâusingâsuchâproducts;âandâtheâincreasedâorâdecreasedâlikelihoodâthatâthoseâwhoâdoânotâuseâtobaccoâproductsâwillâstartâusingâsuchâproducts.ââOnceâtheâFDAâenactsâitsâauthority,âtheâUSâexperienceâwithâproductâregulationâshouldâbeâinstructiveâtoâotherânationsâinâtheâfuture.âInâtheâmeantime,âBrazilâhasâalreadyârecentlyâimplementedâsomeâtobaccoâproductâregulationsâwhoseâresultsâwillâbeâofâinterestâtoâotherâemergingâmarketânations.
Tobaccoâcontrolâinâanâemergingâmarketânation
Brazilâisâironicallyâtheâsecondâlargestâproducerâandâleadingâexporterâofâtobacco,âasâwellâasâtheâsecondâcountryâtoâfullyâsignâtheâFCTC.âItânowâhasâoneâofâtheâstrictestâtobaccoâcontrolâlegislationsâinâtheâworld.âBrazilâhasâimplementedâaâsocietal,âpopulation-orientedâapproachâtoâtobaccoâcontrolâsinceâtheâMinistryâofâHealthâestablishedâtheâNationalâTobaccoâControlâProgramâ(NTCP)âinâ1989âthroughâtheâInstitutoâNacionalâdeâCĂąncer12.âTheâprogrammeâsâinitialâdisseminationâapproachâwasâmotivatedâbyâtheâneedâtoâreachâopinionâmakersâandâformâaâcriticalâmassâwithâtheâaimâofâchangingâsocialâacceptanceâofâsmoking12.âSmokingâwasâseenâatâthatâtimeâasâaâlifestyleâchoiceâandâitâhadâbroadâsocialâacceptanceâinâanâenvironmentalâcontextâofâextensiveâadvertising12.âTheâprogrammeâprioritisedâreachingâthreeâmajorâcommunityâchannels:âschools,âworkâenvironmentsâandâhealthâunits12.âTheâlocalâmediaâwasâincludedâinâthisânetworkâasâanâimportantâvehicleâforâincreasingâtheâpopulationâsâknowledgeâaboutâtheâharmsâofâsmokingâinâorderâtoâreduceâtheâsocialâacceptanceâofâsmokingâandâmotivateâsmokersâtoâquit12.â
Tobaccoâcontrolâeffortsâbeganâwithâlargeâpriceâincreasesâfollowedâbyâstrongâadvertisingârestrictionsâandâhealthâwarnings,âandâlaterâbyâpartialâsmoke-freeâairâlawsâandâincreasedâavailabilityâofâcessationâprogrammes12.âTobaccoâadvertisingâisânowâbanned,âincludingâmassâmedia,âinternetâandâanyâotherâelectronicâmeans,âasâwellââasâsponsorshipâatâculturalâorâsportingâevents.âTheâcountryâhasâcompulsoryâgraphicâwarningsâandâinsertionsâinâpackagingâandâadvertising.âBrazilâsâstatesâandâmunicipalitiesâhaveâalsoâwidelyâadoptedâlocalâlawsâbanningâsmokingâinâclosedâpublicâenvironments,âincludingâbars,ârestaurants,âandâpublicâandâprivateâorganisations.âStrongâpublicâhealthâcampaignsâcontinueâtoâbeâconductedâpromotingâadoptionâofâhealthyâbehavioursâandâlifestyles.
TheâU.S.âFoodâandâDrugâAdministrationâ(FDA)ââhasâbeenâauthorisedâbyâtheâFamilyâSmokingâPreventionâandâTobaccoâControlâActâ(FSPTCA)âinâ2009âtoâsetâstandardsâforâtobaccoâproductâdesign,âcontents,âandâconstituents.
Brazilâhasâoneâofâtheâstrictestâtobaccoâcontrolâlegislationsâinâtheâworld.
Toâdiscourageâsmoking,âtobaccoâpricesââwereâsharplyâincreased,âsmoke-freeâairâlawsâwereâintroducedâandâtobaccoâadvertisingâwasâbanned.
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Understanding the global risk of the tobacco epidemic and its trajectory in an emerging market nation
MajorâaccomplishmentsâofâBrazilâsâtobaccoâcontrolâeffortsâincludeâanâalmostâ50%âdecreaseâamongâbothâmaleâandâfemaleâsmokingâprevalenceâsinceâ198913,â14.âAâpolicyâsimulationâmodelâcalledââSimsmokeâ,âwhichâisâdesignedâtoâisolateâtheâeffectâofâtobaccoâpoliciesâfromâpreviousâtrendsâinâsmokingâprevalence,âestimatedâaâ46%ârelativeâreductionâinâsmokingâprevalenceâfromâ1989âtoâ2010âassociatedâwithâtheâpoliciesâimplementedâ(ReferâtoâFigureâ1)14.âEvidenceâsuggestsâthatâtheâtobaccoâcontrolâeffortsâhaveâalsoâbeenâeffectiveâinâchangingâtheâsocialâacceptabilityâofâsmoking.âEighty-eightâpercentâofâbothâsmokersâandânon-smokersâreportedâtoâbeâagainstâsmokingâinâenclosedâpublicâplaces,âandâaâsimilarâpercentageâofâtheâpopulationâisâextremelyâsupportiveâofâevenâstrongerâthanâexistingâregulationsâforâtobaccoâproducts15.â
Source:âLevyâDâetâalâ14â
Brazilâsâmostârecentâtobaccoâproductâregulationsâmayâbeâgroundbreaking.âTheâANVISAâ(HealthâSurveillanceâAgency)âbannedâflavourâadditivesâtoâcigarettes,âsuchââasâmenthol,âmint,âclove,âcinnamon,âcocoa,âvanilla,âandâothersâbyâMarchâ201416.âIngredientsâsuchâasâthese,âwhenâaddedâtoâcigarettes,âcanâmakeâthemâmoreâattractiveâtoâyoungâpeopleâasâwellâasâmaskâtheâstrongâsmellâandâflavourâtypicalâofâtheâtobaccoâleaf15,â17.âANVISAâalsoâprohibitedâcommercialisation,âimportation,âandâadvertisementâofâanyâelectronicâsmokingâdevicesâ(ieâe-cigarettes),âwhileâtheâsalesâandâpopularityâofâtheseâdevicesâhaveâbeenâgrowingârapidlyâinâotherâcountries15.â
TheâeffectivenessâofâBrazilâsâtobaccoâproductâregulationsâcouldâbeâevaluatedâbyâcomparingâprogressâwithâaâsimilarâemergingâmarketâcountryâsuchâasâMexico,âwhichâdoesânotâhaveâtheseâregulationsâandâcouldâserveâasâaâcontrol.âAsideâfromâproductâregulation,âMexicoâsâtobaccoâcontrolâpoliciesâareâcomparableâtoâthoseâinâBrazilâwithâonlyâaâfewâdifferences.âInâBrazil,â100%âsmoke-freeâindoorâairâpoliciesâcoverâmoreâareasâthanâthoseâofâMexico,âmoreâformsâofâadvertisingâareâbanned,âandâlarger,âgraphic,âandâmoreâinformationalâpackageâwarningsâareârequired.âMexico,âonâtheâotherâhand,âhas:â(1)âsomeâoutdoorâsmoke-freeâpolicies,â(2)âpenaltiesâforânotâpostingâsmoke-freeâsigns,â(3)âprescribesâstepsâforâownersâtoâtakeâinâorderâtoâstopâpersonsâfromâsmoking,â(4)âbansâcigaretteâsalesâthroughâvendingâmachines,âandâ(5)âexplicitlyâbansâfalse,âmisleading,âorâdeceptiveâadvertising,âincludingâtheâprintingâofâtar,ânicotine,âandâcarbonâmonoxideâlevelsâonâpackages18.âTheâmostâprominentâdifferenceâbetweenâtheâtwoâcountriesââtobaccoâcontrolâpoliciesâisâtheâpresenceâorâabsenceâofâtobaccoâproductâregulations.
Sinceâ1989,âsmokingâprevalenceâamongâmenâandâwomenâhasâdecreasedânearlyâ50%.
Figureâ1:âBrazilâsmokingâprevalenceâforâindividualsâagedâ18âyearsâandâabove,â1989â2010:âSimSmokeâpredictionsâandâvariousâsurveys
Flavorâadditivesâhaveâalsoâbeenâbannedâfromâcigarettes.
Mexico,âlikeâBrazil,âhasâstrongâanti-tobaccoâcontrolâpoliciesâinâplace.
Swiss Reâ RiskâDialogueâSeriesâ 39
CurrentâandâfutureâofâriskâforâsmokingâinâBrazil
Despiteâtheânationâsâpolicyâadvances,âBrazilâcontinuesâtoâhaveâaâseriousâtobaccoâproblem.âWhileâtobaccoâconsumptionâhasâdecreasedâoverâtheâlastâdecades,âtheâabsoluteânumberâofâtobaccoâusersâinâtheâcountryâisâstillâveryâhighâ(aroundâ25âmillionâamongâpersonsâ15âyearsâofâageâorâolder)12.âOfâcontinuedâandâmajorâconcernâareâtheâearlyâageâofâsmokingâinitiationâandâtheârelativelyâhighâprevalenceâofâsmokingâamongâwomen.âNineâpercentâofâboysâandâsevenâpercentâofâgirlsâbetweenâagesâ14âandâ18âareâusingâtobacco15,âandâsmokingâisâbecomingâincreasinglyâpopularâamongâwomen.â
Femalesânowâaccountâforâtheâmajorityâ(54%)âofânewâsmokersâinâtheâcountry15.âAsâshownâbyâLopezâetâal,âincreasesâinâfemaleâsmokingâprevalenceâinâaâcountryâtypicallyâlagsâbehindâincreasesâinâmaleâprevalence19â(ReferâtoâFigureâ2).âFemaleâsmokingâisâoftenâdrivenâby:â(1)ââpeerâpressureâ,â(2)âanâassociationâofâsmokingâwithâbeingâstrongerâandâmoreâmature,â(3)âimagesâinârelationâtoâequalârightsâwithâmen,â(4)âaââviewâofâsmokingâasâanâaidâtoâweightâlossâ(insteadâofâeating)âorâweightâgainâoftenâassociatedâwithâquitting,âandâ(5)âincreasingânumbersâofâbrandsâforâfemaleâsmokers15.âTargetedâmarketingâplaysâaâsignificantârole.âFollowingâtheâdevelopmentâandâmarketingâofâmentholâbrandsâtoâyoungâwomen,âJapanâexperiencedâanâupsurgeâinâsmokingâamongâhighâschoolâagedâgirls,âparticularlyâofâmentholâbrands20.â
â
Source:âReproducedâfromâTobaccoâControl,âLopez,âAD,âCollishawâNE,âPihaâTâ(1994).âAâdescriptiveâmodelâofâtheâcigaretteâepidemicâinâdevelopedâcountries.â3:â242-247âwithâpermissionâfromâBMJâPublishingâGroupâLtd.â
Brazilâstillâlacksâanâadvertisingâbanâonâpostersâandâpanels,âonâtheâpackagingâitself,âandâatâpoints-of-sale15.âANVISAâproposedâregulatingâadvertisingâatâretailâpoints-of-saleâandâincreasingâvisibleâwarningsâonâpackages,âalthoughâtheseâpoliciesâhaveânotâyetâbeenâadopted15.âBrazilâsâsmoke-freeâlawsâareâignoredâinâmanyâestablishments.âManyâpeopleâcontinueâtoâsmokeâinâstairwellsâofâpublicâplaces,âsuchâasâtheatres,âhospitals,âlibrariesâandâcinemas.âEnforcementâofâtheâBrazilianâFederalâTobaccoâLegislationâforbiddingâtheâsaleâtoâchildrenâunderâ18âyearsâofâageâremainsâlax15.âIncreasedâapplicationâofâ100%âsmoke-freeâpoliciesâcombinedâwithâenforcement,âvisitsâbyâauthoritiesâandâlargeâfinesâtoâincreaseâcompliance,âcouldâfurtherâdecreaseâtheâcountryâsâsmokingârate15.â
Whileâtobaccoâconsumptionâhasâdecreased,âmoreâthanâ25âmillionâpeopleâinâBrazilâstillâsmoke.â
Smokingâamongâwomenâisâbecomingâincreasinglyâpopular,âwithâwomenâaccountingâforâtheâmajorityâofânewâsmokers.
Figureâ2:âSpreadâofâsmokingâandâsmoking-relatedâmortalityâwithinâaâcountry,âoverâtime
AdvertisingâbansâareânotâinâplaceâinâBrazil.
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Understanding the global risk of the tobacco epidemic and its trajectory in an emerging market nation
CigaretteâspendingâinâBrazilârangesâfromâ4.8%âtoâ7.0%âofâfamilyâexpenditures,âsuggestingâthatâexistingâpriceâandâtaxâpoliciesâareânotâoptimalâandâthatâmoreâcouldâbeâdoneâtoâmakeâcigaretteâpurchaseâlessâaffordable12.âWhileâmonthlyâincomeâorââperâcapitaâincomeâisâanâimportantâindicatorâofâoverallâpurchasingâpower,âaâbetterâindicatorâforâtheâpoorestâsectorsâofâsocietyâisâtheâminimumâwageâdividedâbyâtheâaverageâpriceâofâaâcigaretteâpackage,âwhichâindicatesâtheânumberâofâcigaretteâpackagesâthatâcanâbeâpurchasedâonâaâminimumâwage12.âAsâofâSeptemberâ2008,ââaâlow-incomeâsmokerâcouldâbuyâ150âpackagesâofâcigarettesâaâmonth,âwhileâheâorââsheâcouldâbuyâ83âinâJanuaryâ199612.âTheâMinistryâofâHealthâisâreportedlyâplanningââtoâimplementâaâtaxâincreaseâbyâ2015âtoâincreaseâtheâpriceâofâcigarettesâbyâ55%15.âTheseâpricingâpoliciesâcouldâbeâsignificantâasâtheâpurchasingâpowerâofâtheâBrazilianâpopulationâincreasesâifâtheâpoliciesâobtainâanâacceptableâmarginâforâtheâminimumâwage/cigaretteâpriceâratio12.â
TheâfutureâofâsmokingâinâBrazilâwillâdependâonâtheâbalanceâbetweenâcountervailingâforcesâpromotingâversusâmitigatingâtheâsocialâacceptabilityâandâdesirabilityâofâtobaccoâuseâforâindividuals.âTheâSimsmokeâmodelâwasâalsoâusedâtoâconsiderâtheâpotentialâeffectâofâpoliciesâthatâhadânotâyetâbeenâimplemented.âTheâmodelâestimatedâthatâifâtobaccoâcontrolâpoliciesâareâstrengthenedâinâBrazilâtoâbeâfullyâconsistentâwithâFCTC,âtheâeffectâwouldâbeâtoâdecreaseâsmokingâprevalenceâbyâtheâyearâ2050âbyâupâtoâ39%14.âTheâmodelâdoesânotâconsiderâdirectlyâtheâeffectâofâincomeâandâpurchasingâpowerâonâsmokingâratesâorâfeedbackâthroughâsocialânormsâandâattitudes,âandâpeerâandâfamilyâbehaviours14.âBrazilâsâexperienceâwithâitsânewâtobaccoâproductâregulationsâmayâprovideânewâempiricalâdataâtoâfurtherârefineâtheâmodelâsâpredictions.
Globalisationâandâtheâpotentialâuseâofââbigâdataâ
Theââbigâdataââapproachâmayâbeâanotherâopportunityâtoâgainâinsightâintoâtrendsââinâsmokingâinâemergingâmarketânations.âForâexample,âanalysesâofâaâlongitudinal,âtime-seriesâglobalâdatabaseâofânationsââsocietal,âhumanâandâeconomicâdevelopmentâcharacteristicsâasâwellâotherâdataâcouldârevealâkeyâfactorsâthatâareâassociatedââwithâchangingâsmokingâprevalence.âSuchâdataâareâavailableâfromâaânumberâofâcomprehensive,âglobal,âcountry-specificâsources,âincluding:â(a)âtheâKOFâIndexâofâGlobalization,âwhichâwasâdevelopedâatâtheâKOFâSwissâEconomicâInstituteâandâmeasuresâthreeâmainâdimensionsâofâglobalisation:âeconomic,âsocial,âandâpolitical,âannuallyâforâ207âcountriesâoverâtheâperiodâ1970â201121,â22;â(b)âdetailedâannualâdataâpertainingâtoâtheâpolitics,âeconomy,ârisk,âregulationâandâbusinessâenvironmentâofâcountriesâworldwide,âwhichâareâavailableâfromâtheâEconomicâIntelligenceâUnit23;âandâ(c)âtheâWHOâsâMPOWERâreports,âwhichâincludeâcountryâlevelâdataâpertainingâtoâsixâevidence-basedâtobaccoâcontrolâmeasuresâforâreducingâtobaccoâuseâcorrespondingâtoâtheâacronym24.âTheâmeasuresâare:â(M)âmonitoringâtobaccoâuseâandâpreventionâpolicies;â(P)âprotectingâpeopleâfromâtobaccoâsmoke;â(O)âofferingâhelpâtoâquitâtobaccoâuse;â(W)âwarningâpeopleâaboutâtheâdangersâofâtobacco;â(E)âenforcingâbansâonâtobaccoâadvertising,âpromotionâandâsponsorship;âandâ(R)âraisingâtaxesâonâtobacco.
Preliminaryâanalysisâofâtheseâdataâfoundâthatâpredictorsâofâaânationâsâthreeâyearâchangeâinâsmokingâprevalenceâdifferâforâmalesâandâfemales25.âChangingâmaleâsmokingâprevalenceâwasâpredictedâbyâaânationâsâwealth,âgovernance,âeducationâandâeconomicâglobalisation;âwhereasâchangingâfemaleâsmokingâprevalenceâwasâpredictedâbyâtheâsingleâvariable,âsocialâglobalisation,âasâseenâforâexampleâbyâanâinverseârelationshipâbetweenâchangeâinâsmokingâprevalenceâandâinternetâuse25.âMexicoâsâsocialâglobalisationâindexâwasâ33%âhigherâthanâBrazilâs,âwhileâMexicoâexperiencedâanâaverageâ1.2%â3-yearâdeclineâinâfemaleâsmokingâprevalenceâduringâ1998â2012âcomparedâtoâanâaverageâofâ0.2%âinâBrazil25.âPossibly,âtheâmoreâthatâwomenâinâsocietyâuseâinternetâforâtelecommunications,âsocialâmediaâandânon-face-to-faceâinteractions,âtheâlessâtimeâtheyâmightâspendâwithâothersâin-personâandâtheâ
Spendingâonâcigarettesârangesâfromâ4.8%âtoâ7%âofâfamilyâexpenditures.
TheâfutureâofâsmokingâinâBrazilâwillâdependâtheâbalanceâbetweenâeffortsâthatâpromoteâversusâmitigateâtheâsocialâacceptabilityâofâtobacco.
Theâuseâofââbigâdataââmayârevealâkeyâfactorsâthatâareâassociatedâwithâaâchangeâinâsmokingâprevalence.
Predictorsâofâaânationâsâthreeâyearâchangeâinâsmokingâprevalenceâdifferâbyâgender.
Swiss Reâ RiskâDialogueâSeriesâ 41
lessâexposureâtheyâmayâhaveâtoâtheâsocial,âphysical,âandâpsychologicalâcuesâforâsmokingâthatâencourageâandâreinforceâtobaccoâuse.âTheâdefinitionsâandâboundariesâofâcommunitiesâmayâbeâchangingâinâthisâeraâofâglobalisation,âwhichâmayâhaveâimportantâimplicationsâforâtheâmostâcommonâtypesâofâsocialâinfluencesâonâsmokingâbehaviour.âModelsâthatâareâbasedâonââbigâdataââmayâbeâfurtherârefinedâbyâincorporatingâfurtherâdataâsuchâasâmeasuresâofâpromotional,âorâsupply-side,âinfluences.âInâaddition,âtheâpathâofâtheâtobaccoâepidemicâmayâbeâaffectedâbyâfactorsâhavingâcross-borderâeffects,âincludingâtradeâliberalisation,âdirectâforeignâinvestment,âglobalâmarketing,âtransnationalâtobaccoâadvertising,âpromotionâandâsponsorship,ââandâtheâinternationalâmovementâofâcontrabandâandâcounterfeitâcigarettes.âTradeâliberalisationâmayâincreaseâmarketâcompetition,âwhichâmayâinâturnâleadâtoâlowerâpricesâandâotherâpractices,âsuchâasâincreasedâmarketingâtoâstimulateâdemand26.â
Relevantâcountry-specificâdataâisâalsoâbeingâcollectedâthroughâtheâGlobalâTobaccoâSurveillanceâSystemâ(GTSS)âorganisedâbyâtheâWHOâandâtheâU.S.âCentersâforâDiseaseâControlâandâcanâbeâusedâtoâdescribeâandâanalyseâattitudesâtowardâtobaccoâuse,âmarketingâandâpolicies,âinâadditionâtoâsmokingâbehavioursâamongâyouthâandâadults27.âAâGlobalâYouthâTobaccoâSurveyâ(GYTS)âanalysisâofâyouthâagedâ13âtoâ15âyearsâinââ115âcountries,âprimarilyâinâtheâdevelopingâworld,âexaminedârelationshipsâbetweenâyouthâsupportâforâsmoke-free-policiesâandâsmokingâstatus,âandâexposureâtoâsecondhandâsmoke,âcontrollingâforâdemographicâandâenvironmentalâfactorsâandâcountry-levelâpolicyâfactors30.âTheâmajorityâofâyouthâworldwideâwereâfoundâtoâsupportâsmoke-freeâpoliciesâinâpublicâplaces,âmanyâofâwhomâareâstillâlivingâinâareasâstillâlackingâtheseârules28.âYouthâattitudesâdataâsuchâasâtheseâprovideâaâusefulâwindowâintoâaâsocietyâsâpresentâandâpotentiallyâchangingâsocialânormsâpertainingâtoâsmokingâandâmightâalsoâreflectâimportantâfutureâpolicyâdirections.
Conclusions
Tobaccoâuseâisâaâglobalâriskâofâmajorâimportanceâandâwide-rangingâuncertainty.ââTheâscopeâandâmagnitudeâofâthisâriskâwillâbeâinfluencedâbyâlocal,ânationalâandâglobalâfactorsâandâbyâpromotionalâversusâmitigatingâfactors.âTheâfutureâtrendsâofâtobaccoâuseâinâlowâandâmiddle-incomeâemergingâmarketânationsâsuchâasâBrazilâandâMexicoâareâlikelyâtoâdependâonâtheâmarketingâandâpromotionalâactivitiesâonâoneâhand,âandââonâpublicâhealthâtobaccoâcontrolâpoliciesâonâtheâother,âandâtheirârespectiveâabilitiesââtoâinfluenceâtheâsocietalâacceptabilityâversusâdenormalisationâofâsmoking.âHowâeffectiveâtraditional,âevidence-basedâriskâmitigatingâstrategiesâwillâbeâinâanyânationâdependsâonâwhetherâorânotâtheâmeasuresâareâimplementedâinâaâcomprehensiveâfashionâandâaccompaniedâbyâeffectiveâenforcement.âTheseâpoliciesâwhereâimplementedâhaveâbeenâembracedâbyâsmokersâandânon-smokersâalike,âevenâwhereâsmokersâwereâinitiallyâreluctantâorâwereâopposedâtoâthem.â
However,âongoingâtobaccoâproductâinnovationâandâdevelopmentâtogetherâwithâmarketingâandâpromotionâcontinueâtoâraiseâtheâbarâandâpotentialâneedâforâprogressiveâtobaccoâcontrolâpolicies,âsuchâasâloweringâaddictivenessâthroughâproductâregulation.âBrazilâsâexperienceâinâtheâcomingâyearsâshouldâbeâinformativeâforâregulatoryâauthoritiesâinâotherâemergingâmarketânationsâasâwellâasâtheâUSâandâelsewhere.âRecentââbigâdataââapproachesâcouldâbeâfurtherâaugmentedâwithâdataâthatâgaugeâpublicâopinion,âespeciallyâtheâattitudesâofâyouthâandâwomenâasâpotentialâindicatorsââofâforthcomingâtrends.âIncreasinglyâlargeâdatabasesâandâcomputationalâresourcesâareâbecomingâavailableâtoâtrackâandâprojectâtheâfutureâcourseâofâtheâtobaccoâepidemic,âwhichâmayâbeâtheâsingleâmostâimportantâriskâtoâdetermineâlongevityâandâmortalityââinâtheâ21stâcentury.â
Country-specificâdataâisâbeingâcollectedâtoâanalyseâattitudesâaboutâtobaccoâuse,âmarketing,âpoliciesâandâbehaviours.
Theâriskâofâusingâtobaccoâwillâbeâinfluencedâbyâlocal,ânationalâandâglobalâfactorsâandâbyâpromotionalâversusâmitigatingâfactors.â
Ongoingâtobaccoâproductâinnovationâandâdevelopmentâtogetherâwithâmarketingâandâpromotionâcontinueâtoâhighlightâtheâpotentialâneedâforâprogressiveâtobaccoâcontrolâpolicies.
42â Swiss Reâ RiskâDialogueâSeries
Understanding the global risk of the tobacco epidemic and its trajectory in an emerging market nation
References1.â âWorldâEconomicâForumâ(2012).âInsightâReport:âGlobalâRisksâ2012,ââ
SeventhâEdition,âAnâinitiativeâofâtheâRiskâResponseâNetwork.2.â âEriksenâM,âMackayâJ,âRossâHâ(2012).âTheâTobaccoâAtlas.âFourthâEd.âAtlanta,â
GA.âAmericanâCancerâSociety;âNewâYork,âNY:âWorldâLungâFoundation.3.â âWorldâHealthâOrganizationâ(2004).âBuildingâblocksâforâtobaccoâcontrol:ââ
aâhandbook.âGeneva:âWHO.4.â âTheâTobaccoâInstituteâ(1980).âMemorandumâtoâexecutiveâcommittee:ââ
TheâTobaccoâInstituteâCommunicationsâCommitteeâpresentsâthisâlong-rangeâplanâtoâtheâexecutiveâcommittee.âBatesânumberâTI06431226-TI06431248.
5.â âDurdenâDâ(1977).âFirstâReportâByâWorkingâPartyâOnâSocialâAcceptabilityâOfâSmokingâToâInternationalâCommitteeâOnâSmokingâIssues.âBatesâNumberâ501472755-501472794.
6.â âConnollyâGNâ(2012).âHowâsocietyâtreatsâsmoking.âIsraelâJournalâofâHealthâPolicyâResearch.â1:29.
7.â âPierceâJPâ(2008).âSmoke-freeâpoliciesâareâwide-rangingâandâextremelyâeffective.
8.â âKohâHK,âJoossensâLX,âConnollyâGâ(2007).âMakingâsmokingâhistoryâworldwide.âNewâEnglandâJournalâofâMedicine.â356:â1496â1498.
9.â âTheâWHOâFrameworkâConventionâonâTobaccoâControl,âWorldâHealthâAssemblyâResolutionâ56â(2003).â1,âMayâ21.
10.â âIglesiasâR,âJhaâP,âPintoâM,âSilvaâVLC,âGodinhoâJâ(2007).âControleâdoâTabagismoânoâBrasil;âDepartamentoâdeâDesenvolvimentoâHumano,âRegiĂŁoâdaâAmĂ©ricaâLatinaâeâdoâCaribe,âBancoâMundial.
11.â âFamilyâSmokingâPreventionâandâTobaccoâControlâActâ(2009).âPubâL.â111-31,â123âStatâ1776.
12.â âPanâAmericanâHealthâOrganizationâ(2010).âInstitutoâNacionalâdeâCĂąncerâ(Brazil).âGlobalâAdultâTobaccoâSurveyâBrazilâReport:âRioâdeâJaneiro.
13.â âSzkloâAS,âdeâAlmeidaâLM,âFigueiredoâVC,âAutranâM,âMaltaâDâ(2012).âAâsnapshotâofâtheâstrikingâdecreaseâinâcigaretteâsmokingâprevalenceâinâBrazilâbetweenâ1989âandâ2008.âPreventativeâMedicine.â54:162-167.
14.â âLevyâD,âdeâAlmeidaâLM,âSzkloâAâ(2012).âTheâBrazilâSimSmokeâpolicyâsimulationâmodel:âtheâeffectâofâstrongâtobaccoâcontrolâpoliciesâonâsmokingâprevalenceâandâsmoking-attributableâdeathsâinâaâmiddleâincomeânation.âPLoSâMed.â9(11):e1001336.âdoi:â10.1371/journal.pmed.â1001336.
15.â âPassport:âTobaccoâinâBrazilâ(2013).âEuromonitorâInternational.âOctober.16.â âResolutionâââRDCâNÂșâ14,âofâMarchâ15,â2012â(Brazil).ââ
http://www.tobaccocontrollaws.org/files/live/Brazil/âBrazil%20-%20RDC%20No.%2014_2012.pdf.
17.â âCarpenterâCM,âWayneâGF,âPaulyâJL,âKohâHK,âConnollyâGNâ(2005).ââNewâcigaretteâbrandsâwithâflavorsâthatâappealâtoâyouth:âtobaccoâmarketingâstrategies.âHealthâAffairs.â24:1601-10.
18.â âPassport:âTobaccoâinâMexicoâ(2013).âEuromonitorâInternational.âSeptember.19.â âLopezâAD,âCollishawâNE,âPihaâTâ(1994).âAâdescriptiveâmodelâofâtheâcigaretteâ
epidemicâinâdevelopedâcountries.âTobaccoâControl.â3:242-247.20.â âConnollyâGN,âBehmâI,âOsakiâY,âWayneâGFâ(2011).âTheâimpactâofâmentholâ
cigarettesâonâsmokingâinitiationâamongânon-smokingâyoungâfemalesâinâJapan.âInternationalâJournalâofâEnvironmentalâResearchâandâPublicâHealth.â8(1):1-14.
21.â âDreherâA,âGastonâN,âMartensâPâ(2008).âMeasuringâGlobalisationâââGaugingâitsâConsequences.âNewâYork:âSpringer.
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22.âââDreherâAâ(2006).âDoesâGlobalizationâAffectâGrowth?âEmpiricalâEvidenceâfromâaâNewâIndex,âAppliedâEconomics.â38,â10:1091-1110.
23.â âTheâEconomistâGroupâ(2014).âTheâEconomistâIntelligenceâUnitâLimited.24.â âWHOâReportâonâtheâGlobalâTobaccoâEpidemicâ(2013).âTheâMPOWERâ
package.âGeneva,âWorldâHealthâOrganization.25.â âAlpertâHRâ(2014).âEffectsâofâsocialâandâeconomicâglobalizationâandâ
governanceâonâsmokingâprevalenceâinânations.â18thâAnnualâMeetingâofâSocietyâforâResearchâonâNicotineâandâTobacco.âSeattle,âWA.âFebruaryâ5â8.
26.â âMcGradyâBâ(2012).âConfrontingâtheâtobaccoâepidemicâinâaânewâeraâofâtradeâandâinvestmentâliberalization.âGeneva:âWorldâHealthâOrganization.â
27.â âGlobalâTobaccoâSurveillanceâSystemâCollaboratingâGroupâ(2005).âGlobalâTobaccoâSurveillanceâSystemâ(GTSS):âpurpose,âproduction,âandâpotential.ââTheâJournalâofâSchoolâHealth.â75:15-24.
28.â âKohâHK,âAlpertâHR,âJudgeâCM,âCaugheyâRW,âElquraâLJ,âConnollyâGN,âWarrenâCWâ(2011).âUnderstandingâworldwideâyouthâattitudesâtowardsâsmoke-freeâpolicies:âanâanalysisâofâtheâGlobalâYouthâTobaccoâSurvey.âTobâControl.â20(3):â219-25.
About the author
Hillel R. AlpertDrâHillelâR.âAlpertâisâaâpublicâhealthâscientistâandâexpertâwithâoverâ25âyearsâofâexperienceâconductingâappliedâpolicyâandâscientificâresearchâinâtheâfieldsâofâtobaccoâcontrolâandâepidemiology,âpopulationâsciences,âpharmacoepidemiology;âenvironmentalâhealthâandâepidemiology,âmedicalâethics;âhealthâcareâpolicy,âqualityâandâfinancing;âclinicalâeffectivenessâandâmedicalâdecision-making,âregulatoryâscience,âandâbiomedicine.âHeâearnedâaâBachelorâofâScienceâdegreeâinâHumanâGeneticsâatâMcGillâUniversityâinâ1975,âaâMasterâofâScienceâdegreeâinâHealthâPolicyâandâManagementâatâHarvardâSchoolâofâPublicâHealthâinâ1987,âandâDoctorâofâScienceâdegreeâinâEnvironmentalâHealthâatâtheâHarvardâSchoolâofâPublicâHealthâinâ2013.âDrâAlpertâreceivedâaâpost-doctoralâfellowshipâfromâtheâSwissâRe/âHarvardâSchoolâofâPublicâHealthâSEARCHâProgramâinâwhichâheâexaminedâtheâuseâofââbigâdataââtoâmodelâtheâriskâforâsmokingâandâtobaccoâuseâinâemergingâmarketânations.â
Swiss Reâ RiskâDialogueâSeriesâ 45
Time trends of physical activity practice in Brazil
Due to its harmful health effects and its high prevalence worldwide, physical inactivity is a public health threat. However, little is known about time trends in physical activity, particularly in low and middle-income settings. Brazil is experiencing an increase in the quantity and quality of physical research, including data on time trends. Local and national data indicate a large increase in all domains of physical inactivity, a discrete increase in leisure-time physical activity and a decrease in transportation physical activity in the past years. Changes over time are widening education inequalities.
Introduction
Measuringâtheâimpactâofâaâriskâfactorâonâpublicâhealthâisâaâcomplexâtaskâthatâbasicallyâdependsâonâtheâanswerâtoâtwoâquestions:â(a)âwhatâproportionâofâtheâpopulationâisâexposedâtoâtheâfactor?âandâ(b)âwhatâisâtheâincreaseâinâriskâassociatedâwithâexposureâtoâtheâfactor?âAâsetâofâtwoâstudiesâpublishedâinâ2012âinâTheâLancetâestimatedâtheâimpactâofâphysicalâinactivityâforâpublicâhealthâusingâthisâmethod.âHallalâetâal,âusingâdataâfromâ122âcountries,ârepresentingâaroundâ90%âofâtheâworldâsâpopulation,âshowedâthatâ31.1%âofâtheâadultsâworldwideâdoânotâreachâtheârecommendedâ150âminutesâperâweekâofâmoderateâtoâvigorousâphysicalâactivity1.âLeeâetâalâshowedâthatâinactivityâââdefinedâasânotâachievingâtheârecommendedâlevelâofâphysicalâactivityâââisâresponsibleâforâ6%âofâallâcoronaryâheartâdiseaseâdeaths,â7%âofâtypeâ2âdiabetes-relatedâdeathsâandâ10%âofâallâbreastâandâcolonâcancerâdeaths.âTakenâtogether,âtheseâfindingsâsuggestâthatâoverâ5âmillionâdeathsâperâyearâworldwideâareâattributedâtoâphysicalâinactivity2.
Becauseâtheâpandemicâofâphysicalâinactivityâisâthereforeâaâmajorâpublicâhealthâthreatâforâmodernâsocieties,âregularâmonitoringâofâpopulationâphysicalâactivityâlevelsâisâimportantâforâdecisionâmakingâinâpublicâhealth.âHallalâetâalâsummarisedâtheâprogress,âpitfallsâandâprospectsâofâtheâsurveillanceâofâphysicalâinactivityâaroundâtheâworld1.âAmongâtheâpositiveâdevelopmentsâwere:â(a)âinformationâisâavailableâforâtwo-thirdsâofâtheâcountriesâaroundâtheâworld;â(b)âthereâareâatâleastâtwoâstandardisedâinstrumentsâthatâcanâbeâusedâinâdifferentâculturesâforâmeasuringâphysicalâactivity;âandâ(c)âtheâWorldâHealthâOrganizationâSTEPwiseâapproachâtoâphysicalâactivityâsurveillanceâhasâprovedâtoâbeâofâgreatâutility,âparticularlyâforâlowâandâmiddle-incomeâcountries.âAmongâtheâpitfallsânotedâwere:â(a)âtheâlackâofâdataâwasânotârandomâââieâcountriesâwithânoâdataâonâphysicalâinactivityâareâconcentratedâinâAfricaâandâSoutheastâAsia;â(b)âmostâofâtheâ122âcountriesâcontributingâdataâtoâtheâpublicationâhadâonlyâoneâdataâpoint,âprecludingâin-countryâanalysesâofâtimeâtrends;âandâ(c)âthereâareâfewâdataâavailableâonâactiveâtransportâandâsedentaryâbehaviours1.
Brazilâisâexperiencingâaâtremendousâincreaseâinâtheâquantityâandâqualityâofâphysicalâactivityâresearch3,â4.âInâthisâreport,âweâpresentâtheâsourcesâofâdataâonâtimeâtrendsâofâphysicalâactivityâinâBrazilâandâhighlightâsomeâkeyâfindings.
â
Theâimpactâofâaâriskâfactorâonâpublicâhealthâdependsâonâtheâproportionâofâtheâpopulationâexposedâtoâtheâfactorâandâtheâincreaseâinâriskâassociatedâwithâexposureâtoâtheâfactor.
Regularâmonitoringâofâphysicalâactivityâisâimportantâforâdecision-makingâinâpublicâhealth.
TheâquantityâandâqualityâofâphysicalâactivityâresearchâisâonâtheâriseâinâBrazil.
GrĂ©goreâIâMielke,âPedroâCâHallalâandâI-MinâLee
46â Swiss Reâ RiskâDialogueâSeries
Time trends of physical activity practice in Brazil
Localâdataâsources
Forâyears,âtheâonlyâsourceâofâdataâonâtimeâtrendsâofâphysicalâactivityâinâBrazilâwasâfromâsurveysâinâtheâcityâofâPelotas,âinâtheâsouthâofâtheâcountry.âPelotasâisâaâmedium-sizedâcityâ(~320â000âinhabitants)âlocatedâinâtheâextremeâsouthâofâtheâcountry,ânearâtheâborderâwithâUruguay,âoccupyingâanâareaâofâ1610âkm2,,âwhereâ93.3%âofâtheâinhabitantsâliveâinâurbanâareas.âTheâcityâisâwell-knownâinâscientistâresearchâdueâtoâtheâexistenceâofâbirthâcohortâstudiesâthatâfollowâallâchildrenâbornâinâtheâcityâinâtheâcalendarâyearsâofâ19825,â19936,7âandâ20048.â
Startingâinâtheâearlyâ2000s,âtheâFederalâUniversityâofâPelotasâGraduateâProgramâinâEpidemiologyâconductedâperiodicâhealthâsurveysâofâtheâcityâsâpopulation.âFromâ2002âonwards,âquestionsâonâphysicalâactivityâhaveâbeenâincludedâinâtheâsurveyâinstrument.âAtâthatâpoint,âaârecentlyâdevelopedâshortâversionâofâtheâInternationalâPhysicalâActivityâQuestionnaireâwasâused.âInâorderâtoâmaintainâcomparabilityâoverâtime,âtheâsameâinstrumentâhasâbeenâadministeredâtoâtheâpopulationâinâ2007âandâ2012.â
Theâproportionâofâparticipantsâthatâdidânotâachieveâ150âminutesâperâweekâofâmoderateâtoâvigorousâphysicalâactivityâ(equivalentâtoâ600âkcal/weekâofâenergyâexpenditure)âinâallâdomainsâincreasedâconsiderablyâandâsignificantlyâbetweenââ2002âandâ2007,âandâonlyâmodestlyâ(notâstatisticallyâsignificant)âbetweenâ2007âandâ2012.â(Figureâ1)9
30%
40%
50%
60%
201220072002 Survey Year
Prevalence
41.1
52.054.4
Source:âAdaptedâfromâHallalâetâalâ(2014)9
Betweenâ2002âandâ2007,âtheâincreaseâinâphysicalâinactivityâwasâdominatedâbyâlow-incomeâparticipants,âwhoâbecameâmuchâmoreâinactiveâoverâtime.âFromâ2007âtoâ2012,ânoâmajorâdifferencesâinâtheâtrendsâwereâobservedâaccordingâtoâsocioeconomicâposition.âLookingâoverâtheâten-yearâperiod,âitâwasâobservedâthatâtheâincreaseâinâtheâprevalenceâofâphysicalâinactivityâwasâmuchâmoreâmarkedâinâlow-incomeâindividualsâasâcomparedâtoâhigh-incomeâparticipants;âthisâhigh-incomeâgroupâactuallyâincreasedâtheirâactivityâlevelsâoverâaâ10-yearâperiodâ(Figureâ2).
â10
â5
0
5
10
15
20
D + E (poorest)C B A (richest)
2002â20122007â20122002â2007
Percentage point differences in the prevalence of physical inactivity
Source:âAdaptedâfromâHallalâetâalâ(2014)9â
ForâyearsâtheâonlyâsourceâofâphysicalâactivityâdataâwasâtheâcityâofâPelotas.
TheâFederalâUniversityâofâPelotasâbeganâconductingâhealthâsurveysâinâtheâearlyâ2000s.
Betweenâ2002âandâ2007,âtheâproportionâofâparticipantsâwhoâdidânotâachieveâ150âminutesâofâphysicalâactivityâincreased.
Figureâ1:âPrevalenceâofâphysicalâinactivityâinâPelotas,âBrazil
Lowerâincomeâparticipantsâtendedâtoâbeâlessâphysicallyâactive.
Figureâ2:âChangesâinâtheâprevalenceâofâphysicalâinactivityâaccordingâtoâsocioeconomicâposition,âPelotas,âBrazil
Swiss Reâ RiskâDialogueâSeriesâ 47
AlsoâinâPelotas,âdataâonâleisureâtimeâphysicalâactivityâareâavailableâforâ2003âandâ2010.âInâ2003,â26.8%âofâtheâparticipantsâwereâclassifiedâasâactiveâ(150+âmin/wk)âinâtheirâleisureâtime,âversusâ24.4%âinâ2010.âFurthermore,âtheâproportionâofâsubjectsâreportingâzeroâminutesâperâweekâofâwalking,âmoderateâorâvigorousâphysicalâactivityâwasâvirtuallyâtheâsameâbetweenâ2003âandâ2010â(Figureâ3).10
0%
20%
40%
60%
80%
100%
20102003
Total PAVigorousModerateWalking
71.4 71.6
81.5 83.987.6 86.4
58.1 57.2
Source:âAdaptedâfromâdaâSilvaâetâalâ(2013)10
DataâonâtimeâtrendsâofâphysicalâactivityâamongâadolescentsâareâalsoâavailableâfromâPelotas.âSurveysâusingâcomparableâmethodologyâwereâconductedâinâ2005âandâ2012,âinvestigatingâactiveâtransportationâandâleisure-timeâphysicalâactivity.âTheââprevalenceâofâ<300âminutesâperâweekâofâleisureâtimeâphysicalâactivityâwasâaroundâ74%âinâ2005âandâ72%âinâ2012.âHowever,âtheâproportionâofâadolescentsâusingâactiveâcommutingâtoâandâfromâschoolâdeclinedâfromâ69.0%âinâ2005âtoâ56.5%âinâ2012ââ(Figureâ4)11.âTheâpotentialâimplicationsâofâsuchâaâdeclineâareâworthâconsidering.âUsingâdataâfromâtheâ1993âPelotasâBirthâCohort,âMartinez-Gomesâetâalâshowedâthatâboysâwhoâreportedâmoreâtimeâinâtransportationâphysicalâactivityâthroughâadolescenceâhad,âonâaverage,ââ2.09âcmâofâwaistâcircumferenceâandââ1.11âcmâofâtrunkâfatâmassâcomparedâtoâboysâusingâpassiveâmodesâofâtransportation17.
0%
20%
40%
60%
80%
100%
20122005
Walking or cycling to/from school
< 300 min/wk leisure-time physical activity
73.7 71.969.0
56.4
Prevalence
â
Source:âAdaptedâfromâCollâetâalâ(2014)11
DataâonâtrendsâofâphysicalâactivityâinâtheâstateâofâSĂŁoâPaulo12âhaveâalsoâbeenâpreviouslyâpublished.âHowever,âbecauseâtheâtrendsâinâthatâstateâareâlikelyâinfluencedâbyâaâmassiveâhealthâpromotionâinterventionâthatâoccurredâinâtheâstate,âweâoptedânotâtoâpresentâthemâhere.
Leisure-timeâphysicalâactivityâaccordingâtoâPelotasâwasâstableâbetweenâ2003âandâ2010.â
Figureâ3:ââProportionâofâindividualsâwithâzeroâminutesâperâweekâofâdifferentâintensitiesâofâleisureâtimeâphysicalâactivity
Surveysâfoundâthatâadolescentsâwhoseâcommuteâtoâandâfromâschoolâinvolvedâphysicalâactivityâwereâlessâlikelyâtoâbeâoverweight.
Figureâ4:âChangesâinâleisureâtimeâandâtransportationâphysicalâactivityâamongâadolescents
48â Swiss Reâ RiskâDialogueâSeries
Time trends of physical activity practice in Brazil
Nationalâdataâsources
TheâlandmarkâstudyâinâtermsâofâsurveillanceâofâphysicalâactivityâinâBrazilâisâtheâSurveillanceâSystemâofâProtectiveâandâRiskâFactorsâforâChronicâDiseasesâThroughâTelephoneâInterviewsâ(VIGITEL).âTheâsystemâwasâimplementedâinâ2006âandâcollectsâdataâonâriskâfactorsâforâchronicâdiseases,âincludingâphysicalâactivity,âyearlyâonâapproximatelyâ54â000âadultsâ(~2000âinâeachâstateâcapital).âDataâareâcollectedâonâleisure-timeâphysical,âtransportation,âwork-relatedâandâhouseworkâphysicalâactivity.â
Theâdataâonâleisure-timeâphysicalâactivityâfromâ2006âtoâ2012âshowsâaâslightâincreaseâinâtheâproportionâofâadultsâreportingâphysicalâactivityâatâleastâfiveâdaysâperâweekâforâatâleastâ30âminutesâperâdayâ(Figureâ5)13.âStudiesâonâtimeâtrendsâinâleisure-timeâphysicalâactivityâhaveâmostlyâcomeâfromâhighâincomeâcountries,âsuchâasâEngland14,âCanada15âandâtheâUnitedâStates16âââeachâshowingâmodestâincreasesâinâleisure-timeâphysicalâactivity,âasâwasâobservedâinâBrazil.âTheâincreaseâinâleisure-timeâphysicalâactivityâinâBrazilâcouldâbeâdueâtoâeffortsâbyâtheâMinistryâofâHealthâtoâpromoteâphysicalâactivity,âtherebyâreducingâtheâburdenâofânon-communicableâdiseases17,18.
0%
5%
10%
15%
20%
FemaleMale
2012201120102009200820072006
Prevalence of leisure-time physical activity
Source:âAdaptedâfromâMielkeâetâalâ(2014)13
Forâtransport-relatedâphysicalâactivity,âdecliningâtrendsâwereâobservedâbetweenâ2006âandâ2008âandâagainâbetweenâ2009âandâ2012â(Figureâ6).âTheâtwoâperiodsâneedâtoâbeâevaluatedâseparatelyâdueâtoâsmallâchangesâinâtheâquestionsâaskedâaboutâsuchâactivityâfromâ2009âonwards.âTheâproportionâofâadultsâthatâreportedâwalkingâorâbikingâforâ30âminutesâorâmoreâperâdayâdecreasedâ12.9%âperâyearâfromâ2006âtoâ2008âandâ5.8%âperâyearâfromâ2009âtoâ201213.âPartâofâthisâchangeâcouldâbeâaâconsequenceâofâtheâcountryâsâeconomicâgrowth.âThereâwereâmarkedâimprovementsâinâtheâproportionâofâtheâpopulationâthatâisâeducated,âresultingâinâaâbetterâsocioeconomicâprofileâand,âconsequently,âincreasedâlikelihoodâofâcarâownership.âForâexample,âwhileâtheâBrazilianâpopulationâincreasedâbyâ12%âbetweenâ2000âandâ201019,âtheânumberâofâvehiclesâincreasedâbyâaroundâ140%âbetweenâ2001âandâ201220.
0%
5%
10%
15%
20%
2012201120102009200820072006
Transportation physical activity
10.9% 10.7%
8.2%
12.8% 13.4%11.4% 11.0%
Source:âAdaptedâfromâMielkeâetâalâ(2014)13
TheâVIGITELâstudyâcollectsâdataâonâriskâfactorsâforâchronicâdiseasesâasâwellâasâphysicalâactivity.
Leisure-timeâphysicalâactivityâdidâincreaseâinâbothâmenâandâwomenâfromâ2006âtoâ2012,âinâpartâdueâtoâeffortsâbyâtheâMinistryâofâHealth.
Figureâ5:âPrevalenceâofâleisure-timeâphysicalâactivityâ(physicalâactivityâatâleastâfiveâdaysâperâweekâforâatâleastâ30âminutesâperâday)âbyâgender.âBrazil,â2006â2012
Transport-relatedâphysicalâactivityâhasâdeclinedâsinceâ2006,âperhapsâdueâtoâincreasesâinâtheânumberâofâvehiclesâpurchased.
Figureâ6:âPrevalenceâofâtransportationâphysicalâactivityâ(walkingâorâcyclingâto/fromâworkâforâatâleastâ30âminutesâperâday).âBrazil,â2006â2012
Swiss Reâ RiskâDialogueâSeriesâ 49
Impactâofâinactivityâonâtheâburdenâofânon-communicableââdiseasesâinâBrazil
TakingâintoâaccountâdataâpresentedâbyâLeeâetâal2âinâ2012,âitâisâpossibleâtoâestimateâtheâimpactâofâtheâpandemicâofâphysicalâinactivityâonâtheâburdenâofânon-communicableâdiseasesâ(NCDs)âinâBrazilâ(Tableâ1).âAlmostâ150000âdeathsâperâyearâ(13.2%âofâallâdeaths)âcouldâbeâavertedâifâtheâentireâpopulationâofâtheâcountryâbecomeâactiveâatârecommendedâlevels.
Cause mortality PAF Adjusted (%)2 Absolute deaths21 Avoidable deaths
Coronaryâheartâdisease 8.2 96,386 7,904
Typeâ2âdiabetes 10.1 52,104 5,263
Breastâcancer 13.4 12,098 1,621
Colonâcancer 14.6 12,471 1,821
All-causeâmortality 13.2 1,103,088 145,608
Source:âLeeâetâalâ(2012)2,âMinistryâofâHealth21
Conclusion
Inâsummary,âitâisâimportantâtoâcontinueâmonitoringâphysicalâactivityâlevelsâinâtheâcountryâatâbothâtheânationalâandâlocalâlevels.âItâisâequallyâimportantâtoâdevelopâpoliciesâthatâpromoteâactiveâlifestylesâinâanâeffortâtoâreduceâtheâburdenâofânon-communicableâdiseasesâonâtheâBrazilianâpopulation.
Increasedâphysicalâactivityâwouldâsignificantlyâreduceâtheâburdenâofânon-communicableâdiseases.â
Tableâ1:âEstimatedâpopulationâattributableâfractionsâ(PAF),âcalculatedâusingâadjustedârelativeârisks,âforâCHD,âtypeâ2âdiabetes,âbreastâcancer,âcolonâcancer,âandâallâcauseâmortalityâassociatedâwithâphysicalâinactivity.âBrazil,â2009.
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Time trends of physical activity practice in Brazil
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8.â âSantosâIS,âBarrosâAJ,âMatijasevichâA,âDominguesâMR,âBarrosâFC,âVictoraâCGâ(2011).âCohortâprofile:âtheâ2004âPelotasâ(Brazil)âbirthâcohortâstudy.âInternationalâJournalâofâEpidemiology.â40:1461-8.
9.â âHallalâPC,âCordeiraâKL,âKnuthâAG,âMielkeâGI,âVictoraâCGâ(2014).âTen-yearâtrendsâinâtotalâphysicalâactivityâpracticeâinâBrazilianâadults:â2002â2012.âJournalâofâPhysicalâActivityâandâHealth.â
10.â âdaâSilvaâIC,âKnuthâAG,âMielkeâGI,âAzevedoâMR,âGoncalvesâH,âHallalâPCâ(2013).âTrendsâinâLeisure-TimeâPhysicalâActivityâinâaâSouthernâBrazilianâCity:ââ2003â2010.âJournalâofâPhysicalâActivityâ&âHealth.
11.â âCollâCdeâV,âKnuthâAG,âBastosâJP,âHallalâPC,âBertoldiâADâ(2014).âTimeâtrendsâofâphysicalâactivityâamongâBrazilianâadolescentsâoverâaâ7-yearâperiod.âTheâJournalâofâAdolescentâHealth:âofficialâpublicationâofâtheâSocietyâforâAdolescentâMedicine.â54:209-13.
12.â âMatsudoâVK,âMatsudoâSM,âAraujoâTL,âAndradeâDR,âOliveiraâLC,âHallalâPCâ(2010).âTimeâtrendsâinâphysicalâactivityâinâtheâstateâofâSaoâPaulo,âBrazil:ââ2002â2008.âMedicineâandâScienceâinâSportsâandâExercise.â42:2231-6.
13.â âMielkeâGI,âHallalâPC,âMaltaâDC,âLeeâI-Mâ(2014).âTimeâtrendsâofâphysicalâactivityâandâtelevisionâviewingâtimeâinâBrazil:â2006-2012.âInternationalâJournalâofâBehavioralâNutritionâandâPhysicalâActivity.â
14.â âStamatakisâE,âChaudhuryâMâ(2008).âTemporalâtrendsâinâadultsââsportsâparticipationâpatternsâinâEnglandâbetweenâ1997âandâ2006:âtheâHealthâSurveyâforâEngland.âBritishâJournalâofâSportsâMedicine.â42:901-8.
15.â âBruceâMJ,âKatzmarzykâPTâ(2002).âCanadianâpopulationâtrendsâinâleisure-timeâphysicalâactivityâlevels,â1981â1998.âCanadianâJournalâofâAppliedâPhysiology.â27:681-90.
16.â âCentersâforâDiseaseâControlâ(2006).âPrevention:âTrendsâinâstrengthâtrainingâ-âUnitedâStates,â1998-2004.âMMWRâMorbâMortalâWklyâRep.â55:769-772.â
17.â âBrasil.âMinistĂ©rioâdaâSaĂșdeâ(2012).âStrategicâactionâplanâtoâtackleâchronicânoncommunicableâdiseaseâinâBrazilâ2011â2022.âBrasĂlia:âMinistĂ©rioâdaâSaĂșde,â2011â(inâPortuguese).
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18.â âBrasil.âMinistĂ©rioâdaâSaĂșde.âSecretariaâdeâVigilĂąnciaâemâSaĂșde.âSecretariaâdeâAtençãoâĂ âSaĂșde.âPolĂticaâNacionalâdeâPromoçãoâdaâSaĂșde.â[http://bvsms.saude.gov.br/bvs/publicacoes/politica_nacional_promocao_saude_3ed.pdf]
19.â âIBGE.âInstitutoâBrasileiroâdeâGeografiaâeâEstatĂstica.â[http://www.ibge.gov.br].â20.â âBrasil.âMinistĂ©rioâdasâCidades,âSistemaâNacionalâdeâRegistroâdeâVeĂculos/
RENAVAM,âSistemaâNacionalâdeâEstatĂsticaâdeâTrĂąnsito/SINETââ[http://www.denatran.gov.br/frota].âAccessedâFebâ14â2014.â
21.â âDATASUS.âMinistĂ©rioâdaâSaĂșde.âDatasus.âMortalidadeâââBrasil.âĂbitosâp/OcorrĂȘnciaâsegundoâCausaâââCID-BR-10.âAvailableâfromâURL:âwww.datasus.gov.brâ[InformaçÔesâdeâSaĂșde:âEstatĂsticasâvitais:âmortalidadeâeânascidosâvivos:âMortalidadeâgeralâââdesdeâ1979:âRegiĂŁoâeâUnidadeâdaâFederação].âAccessedâJulyâ20â2014.
About the authors
GrĂ©gore Mielke GrĂ©goreâMielkeâisâaâPhDâstudentâinâEpidemiologyâatâtheâUniversidadeâFederalâdeâPelotasâinâsouthernâBrazil.âHeâisâworkingâunderâtheâlocalâsupervisionâofâDr.âPedroâHallal,âandâalsoâwithâsupervisionâfromâProf.âI-MinâLeeâfromâHarvard.âTheâfocusâofâhisâworkâisâtoâevaluateâtimeâtrendsâofâphysicalâactivityâandâsedentaryâbehaviourâinâBrazil.âHisâspecificâresearchâtopicâisâtheâstudyâofâsocialâinequitiesâinâphysicalâactivityâandâsedentaryâbehaviours,âasâwellâasâtheâhealthâconsequencesâofâphysicalâactivityâandâsedentaryâbehaviour.âHisâworkâisâbasedâinâBrazil.
Pedro C. Hallal PedroâHallalâisâAssociateâProfessorâatâtheâUniversidadeâFederalâdeâPelotasâinâBrazil.âHeâreceivedâhisâBAâinâPhysicalâEducation,âandâMScâandâPhDâinâEpidemiologyâfromâtheâUniversidadeâFederalâdeâPelotas.âHisâresearchâfocusesâonâphysicalâactivityâandâhealth,âwithâfiveâinterrelatedâthemes:â(i)physicalâactivityâlevels,âtrendsâandâmeasurement;â(ii)âdeterminantsâandâcorrelatesâofâphysicalâactivity;â(iii)âhealthâconsequencesâofâphysicalâactivity;â(iv)âphysicalâactivityâinterventions;â(v)âglobalâactionâforâphysicalâactivityâpromotion.
I-Min Lee I-MinâLeeâisâaâProfessorâinâtheâDepartmentâofâEnvironmentalâEpidemiologyâatâtheâHarvardâSchoolâofâPublicâHealth.âSheâreceivedâherâBachelorâofâMedicineâandâBachelorâofâSurgeryâfromâtheâNationalâUniversityâofâSingapore,âherâMasterâofâPublicâHealthâfromâtheâHarvardâSchoolâofâPublicâHealthâandâherâDoctorâofâScienceâfromâtheâHarvardâSchoolâofâPublicâHealth.âDr.âLeeâsâmainâresearchâinterestâisâinâtheâroleâofâphysicalâactivityâinâpromotingâhealthâandâpreventingâchronicâdisease.âThisâextendsâtoâcharacteristicsâassociatedâwithâaâphysicallyâactiveâwayâofâlife,âsuchâasâtheâmaintenanceâofâidealâbodyâweight.âSheâisâalsoâconcernedâwithâissuesârelatingâtoâwomenâsâhealth.âAtâpresent,âsheâisâprimarilyâinvolvedâinâtwoâresearchâprojects:â(i)âtheâCollegeâAlumniâHealthâStudy,âaâprospectiveâcohortâstudyâofâtheâpredictorsâ(particularly,âphysicalâinactivity)âofâchronicâdiseases,âandâ(ii)âtheâWomenâsâHealthâStudy,âaâcompletedârandomisedâtrialâ(1992-2004)âofâaspirinâandâvitaminâE,âwithâwomenâcurrentlyâbeingâfollowedâonâanâobservationalâbasis,âandâincludingâaccelerometerâmeasuresâofâphysicalâactivity.
Swiss Reâ RiskâDialogueâSeriesâ 53
Acknowledgement
InâJanuaryâ2013,âSwissâReâandâtheâHarvardâSchoolâofâPublicâHealthâ(HSPH)âlaunchedâtheâresearchâcollaborationâSEARCH,âtheâSystematicâExplanatoryâAnalysesâofâRiskâfactorsâaffectingâCardiovascularâHealth,âtoâbetterâunderstandâtheârelationshipâbetweenâriskâfactorsâandâhealthâoutcomes.âAsâoneâofâtheâworldâsâleadingâreinsurers,âSwissâReâseeksâmoreâaccurateâprojectionsâofâglobalâmorbidityâandâmortality.âHSPHâseeksâtoâbetterâunderstandâtheâmostâimportantâdeterminantsâofâhealthâandâtoâimproveâhealthâstatusâglobally.
SwissâRe,âSwissâReâFoundationâandâtheâSwissâReâCentreâforâGlobalâDialogueâ(CGD)âhaveâfundedâthisâjointâresearchâinitiativeâwhichâcameâtoâanâendâinâJulyâ2014.âTheââfocusâofâSEARCHâwasâonâriskâfactorsâforâcardiovascularâdiseaseâandâstrokeâinâBrazil,âMexico,âChinaâandâIndia.âTheseâfourâcountriesâareâflagshipsâforârapidâdevelopmentâandârapidâevolutionâofâaâvarietyâofâhealthâriskâfactorsâthatâwillâdetermineâmorbidity,âmortalityâandâlongevity.âTheâpostdoctoralâfellowsâlistedâbelowâwereâawardedâgrantsâtoâconductâresearchâbasedâonâexistingâdataâsetsâandâcohorts,âandâwereâaccompaniedâbyâmentorsâfromâHSPHâandâSwissâRe.
Thisâpublicationâwouldânotâhaveâbeenâpossibleâwithoutâtheâsupportâofâaânumberââofâpeople.â
Weâwouldâlikeâtoâespeciallyâthankâtheâfellows,âmentors,âcollaboratorsâandâtheâorganisingâcommitteeâforâtheirâcontributions.ââ
HSPH fellowsHillelâAlpertâHiramâBeltrĂĄn-SĂĄnchezâShilpaâBhupathirajuâDanielâCorsiâMartinâLajousYanpingâLiGrĂ©goreâMielkeJenniferâNguyenâMarciaâOttoClaudiaâSuemotoHongyuâWu
HSPH mentorsGregoryâConnollyGoodarzâDanaeiâDouglasâDockeryFrankâHuI-MinâLeeâDariushâMozaffarianâLuâQiSubuâSubramanianâQiâSun
Swiss Re collaborators HimanshuâBhatiaâHueyfangâChenBrianâIvanovicâKenâKrauseEduardoâLaraâDavidâLuâXiaojieâWangUrsâWidmerMonicaâWilsonâ
Other collaboratorsMarciaâCastroPedroâHallalTedâHensonDavidâHunterWilliamâHsiaoAnneâLuskSaileshâMohanC.âArdenâPopeâIIIWalterâWillettâ
Lown Institute collaboratorsBernardâLownSrinathâReddyVikasâSaini
Organising committeeJosephâBrain,âHSPHDouglasâDockery,âHSPHAnnabelleâHett,âSwissâReâCGDFrankâHu,âHSPHChristophâNabholz,âSwissâReâCGDAndreasâObrist,âSwissâReâCGDâHelenâChungâPatterson,âSwissâReDanielâRyan,âSwissâReNancyâLongâSieber,âHSPHâMichelleâWilliams,âHSPHâThomasâZeltner,âWHO
54â Swiss Reâ RiskâDialogueâSeries
Sponsors
TheâSwissâReâGroupâisâaâleadingâwholesaleâproviderâofâreinsurance,âinsuranceâandâotherâinsurance-basedâformsâofâriskâtransfer.âDealingâdirectâandâworkingâthroughââbrokers,âitsâglobalâclientâbaseâconsistsâofâinsuranceâcompanies,âmid-to-large-sizedâcorporationsâandâpublicâsectorâclients.âFromâstandardâproductsâtoâtailor-madeâcoverageâacrossâallâlinesâofâbusiness,âSwissâReâdeploysâitsâcapitalâstrength,âexpertiseâandâinnovationâpowerâtoâenableâtheâriskâtakingâuponâwhichâenterpriseâandâprogressâinâsocietyâdepend.
HarvardâSchoolâofâPublicâHealthâbringsâtogetherâdedicatedâexpertsâfromâaâwideârangeâofâdisciplinesâtoâeducateânewâgenerationsâofâglobalâhealthâleadersâandâproduceâpowerfulâideasâthroughârigorousâresearchâthatâcanâtransformâtheâlivesâandâhealthâofâpeopleâeverywhere.âEachâyearâmoreâthanâ400âfacultyâmembersâatâHSPHâteachâ1200-plusâfull-timeâstudentsâfromâaroundâtheâworld,âasâwellâasâtrainâthousandsâmoreâthroughâonlineâandâexecutiveâeducationâactivities.âOurâeducationalâprogramsâandââresearchâeffortsârangeâfromâtheâmolecularâbiologyâofâAIDSâtoâtheâepidemiologyâofâcancer;âfromâviolenceâpreventionâtoâhealthyâlifestylesââandânutrition;âfromâmaternalâandâchildrenâsâhealthâtoâenvironmentalâhealth;âfromâUSâhealthâpolicyâtoâinternationalâhealthâandâhumanârights.
TheâSwissâReâCentreâforâGlobalâDialogueâisâaâplatformâforâtheâexplorationâofâkeyâglobalâissuesâandâtrendsâfromâaâriskâtransferâandâfinancialâservicesâperspective.âFoundedââbyâSwissâRe,âoneâofâtheâworldâsâlargestâandâmostâdiversifiedâreinsurers,âinâ2000,ââthisâstate-of-the-artâconferenceâfacilityâpositionsâSwissâReâasâaâglobalâleaderâatâtheâforefrontâofâindustryâthinking,âinnovationâandâworldwideâriskâresearch.âTheâCentreâfacilitatesâdialogueâbetweenâSwissâRe,âitsâclientsâandâothersâfromâtheâareasâofâbusiness,âscience,âacademia,âandâpolitics.
SwissâReâFoundationâisâaânon-profitâorganisationâcommittedâtoâcareâandâconcernââforâsocietyâandâtheâenvironment.âLaunchedâinâ2012âbyâglobalâre/insurerâSwissâRe,âtheâFoundationâaimsâtoâmakeâpeopleâmoreâresilientâtowardsânaturalâhazards,âclimateâchange,âpopulationâgrowth,âwaterâscarcityâandâpandemics,âalongâwithâotherâchallengesâtoâsocietyâsâsecurity,âhealthâandâprosperity.âItâalsoâsupportsâcommunityâprojectsâandâemployeeâvolunteeringâinâlocationsâwhereâSwissâReâhasâoffices.
TheâRiskâDialogueâSeriesâofâtheâSwissâReâCentreâforâGlobalâDialogueâisâdesignedâtoâinformâreadersâaboutâongoingâdebatesâandâdiscussionsâbetweenâSwissâReâandâtheâstakeholdersâofâriskâandâinsuranceâbusinessâissues.â
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