Progress towards reducing premature NCD mortality
Authors: Tim Adair
Journal: The Lancet Global Health (2018)

The Sustainable Development Goal (SDG) 3.4, which aims to reduce premature mortality from non-communicable diseases (NCDs) by a third between 2015 and 2030, is a key international public health goal in the context of rising NCD burden in much of the world. In The Lancet Global Health, the study by Bochen Cao and colleagues1Cao B Bray F Ilbawi A Soerjomataram I Effect on longevity of one-third reduction in premature mortality from non-communicable diseases by 2030: a global analysis of the Sustainable Development Goal health target.Lancet Glob Health. 2018; 6: e1288-e1296Summary Full Text Full Text PDF PubMed Scopus (61) Google Scholar measures how achievement of this target, as well as the elimination of all premature mortality from NCDs, will improve longevity in 183 countries. Cao and colleagues assess the effect on longevity as change in the expected life-years lived by people aged 30–70 years, a measure adapted from demographic life table techniques. The study found that achieving a one-third reduction in premature mortality from all NCDs will increase global expected life-years lived by people aged 30–70 years by 0·80 years, while achieving the same reduction from the four main NCDs—cardiovascular diseases (CVDs), cancers, chronic respiratory diseases, and diabetes—will lead to an increase of 0·64 years. These increases might appear small but, in 2015, the global expected life-years lived by people aged 30–70 years was 36·7 of the maximum possible 40·0 years, therefore gains of this size are substantial. These findings show that the greatest impact of achieving this target would be felt in low-income and lower-middle-income countries, where premature mortality from NCDs, particularly CVDs, is highest. Many of these countries are having slow declines, and even increases, in NCD burden due to lifestyle-related risk factors such as smoking, poor diet, physical inactivity, obesity, diabetes, and high blood pressure and cholesterol.2Global Burden of Disease Collaborative NetworkGlobal Burden of Disease Study 2016 (GBD 2016) results.http://ghdx.healthdata.org/gbd-results-toolDate: 2017Date accessed: October 2, 2018Google Scholar Cao and colleagues' findings provide the motivation for national and international efforts to implement proven effective interventions to reduce smoking and excessive alcohol usage, promote improved diet and exercise, and introduce more comprehensive screening and treatment of NCDs. Cao and colleagues provide a pessimistic prognosis for the feasibility of low-income and lower-middle-income countries achieving the one-third reduction target, on the basis of trends from 2000 to 2015. However, evidence from the epidemiological transition of high-income countries shows that long-term NCD mortality change is rarely linear. The decline in NCD mortality in high-income countries in the past decades commonly followed an extended period of slow declines or even increases, such as what is currently happening in low-income and middle-income countries (LMICs). In Australia, for example, male age-standardised NCD mortality in ages 30–69 years increased by 9% from 1950 to 1970, before declining by 43% from 1970 to 1990, primarily because of CVD declines due to successful anti-smoking interventions and reductions in blood pressure and cholesterol.3Taylor R Dobson A Mirzaei M Contribution of changes in risk factors to the decline of coronary heart disease mortality in Australia over three decades.Eur J Cardiovasc Prev Rehabil. 2006; 13: 760-768Crossref PubMed Scopus (52) Google Scholar, 4Adair T Hoy D Dettrick Z Lopez AD Reconstruction of long-term tobacco consumption trends in Australia and their relationship to lung cancer mortality.Cancer Causes Control. 2011; 22: 1047-1053Crossref PubMed Scopus (24) Google Scholar, 5GBD Causes of Death CollaboratorsGlobal, regional, and national age-sex specific mortality for 264 causes of death, 1980–2016: a systematic analysis for the Global Burden of Disease Study 2016.Lancet. 2017; 390: 1151-1210Summary Full Text Full Text PDF PubMed Scopus (2986) Google Scholar For LMICs, the successful introduction of proven interventions to reduce these risk factors, as occurred in high-income countries, would see much quicker declines in the coming years than in 2000–15 and greater likelihood of reducing premature NCD mortality by a third.6WHOWorld Economic ForumFrom burden to “best buys”: reducing the economic impact of non-communicable diseases in low- and middle-income countries. World Economic Forum, Geneva2011Google Scholar Similarly, the current slowdowns in CVD mortality decline in high-income countries—as it becomes more challenging for risk factor prevalences to decline below already low levels—suggest that, in these countries, the one-third reduction target by 2030 might be more difficult to reach than past trends indicate.2Global Burden of Disease Collaborative NetworkGlobal Burden of Disease Study 2016 (GBD 2016) results.http://ghdx.healthdata.org/gbd-results-toolDate: 2017Date accessed: October 2, 2018Google Scholar Cao and colleagues did not include the analytical perspective of the comparison between male and female trends in NCD mortality. Although SDG 3.4 does not include a sex-specific target, changes in NCD premature mortality commonly differ between men and women because of their respective risk factor prevalences. The experience of high-income countries shows that the NCD mortality peaks of men were substantially higher than those of women, largely because of higher smoking rates, although they subsequently declined more rapidly.5GBD Causes of Death CollaboratorsGlobal, regional, and national age-sex specific mortality for 264 causes of death, 1980–2016: a systematic analysis for the Global Burden of Disease Study 2016.Lancet. 2017; 390: 1151-1210Summary Full Text Full Text PDF PubMed Scopus (2986) Google Scholar Men currently have substantially higher premature NCD mortality than women in LMICs, therefore the achievement of SDG 3.4 would primarily be driven by declines in male mortality and reduction in male risk factor prevalences.2Global Burden of Disease Collaborative NetworkGlobal Burden of Disease Study 2016 (GBD 2016) results.http://ghdx.healthdata.org/gbd-results-toolDate: 2017Date accessed: October 2, 2018Google Scholar This study uses WHO's Global Health Estimates, which obtain mortality data from a range of sources—including civil registration and vital statistics (CRVS) systems—and make various adjustments to all-cause and cause-specific mortality data of suboptimal quality.7WHOGlobal health estimates 2015: deaths by cause, age, sex, by country and by region, 2000–2015. World Health Organization, Geneva2016Google Scholar Effective monitoring of many SDGs is reliant on reliable and timely CRVS data; however, only 48% of deaths globally are registered and have a cause.8WHOWorld Health Statistics 2017: monitoring health for the SDGs, Sustainable Development Goals. World Health Organization, Geneva2017Google Scholar There are various efforts to improve CRVS systems by bilateral, multilateral, and philanthropic donors, such as the Bloomberg Data for Health Initiative, the Global CRVS Scaling Up Investment Plan of the World Bank and WHO, the Centre of Excellence for Civil Registration and Vital Statistics Systems of the International Development Research Centre, and the Asia-Pacific CRVS Decade (2015–2024).9AbouZahr C de Savigny D Mikkelsen L et al.Civil registration and vital statistics: progress in the data revolution for counting and accountability.Lancet. 2015; 386: 1373-1385Summary Full Text Full Text PDF PubMed Scopus (143) Google Scholar, 10World BankWHOGlobal civil registration and vital statistics: a scaling up investment plan 2015–2024. World Bank Group, Washington, DC2014Google Scholar The integration into CRVS systems of routine automated verbal autopsies, which ascertain the probable cause of death from interviews with a family member of the deceased, will further improve the evidence base to accurately assess progress of this important public health goal.11de Savigny D Riley I Chandramohan D et al.Integrating community-based verbal autopsy into civil registration and vital statistics (CRVS): system-level considerations.Glob Health Action. 2017; 10: 1272882Crossref PubMed Scopus (45) Google Scholar I declare no competing interests. Effect on longevity of one-third reduction in premature mortality from non-communicable diseases by 2030: a global analysis of the Sustainable Development Goal health targetA one-third reduction in premature mortality from the major NCDs in 2015–30 would have substantial effects on longevity. High-level political commitments to effective and equitable national surveillance and prioritised prevention, early detection, and treatment programmes tailored to the major NCD types are needed urgently in lower-resourced settings if this SDG target is to be met by 2030. Full-Text PDF Open Access