ABSTRACT

OBJECTIVE

To estimate the proportions of awareness, treatment, and control of diabetes mellitus (DM) in the Brazilian adult population.

METHOD

This is a cross-sectional study, with data from a representative sample of the Brazilian population, taken from the National Health Survey(PNS 2014/2015). Outcomes were defined based on glycated hemoglobin (HbA1c) measurements, self-reported DM diagnosis, and use of hypoglycemic agents or insulin. The proportion of DM awareness, treatment, and control was estimated according to sociodemographic characteristics, health conditions, and access to health services, and their respective 95% confidence intervals.

RESULTS

DM prevalence in the Brazilian population was of 8.6% (95%CI: 7.8–9.3): 68.2% (95%CI: 63.9–72.3) were aware of their diagnosis, 92.2% (95%CI: 88.6–94.7) of those who were aware were undergoing drug treatments, and, of these, 35.8% (95%CI: 30.5–41.6) had controlled HbA1c levels. The proportions of DM awareness, control, and treatment were lower in men aged 18 to 39 years, individuals with low education, without health insurance, and beneficiaries of the Bolsa Família program.

CONCLUSION

Approximately one in ten Brazilians has DM. A little more than half of this population is aware of their diagnosis, a condition measured by HbA1c dosage and clinical diagnosis. Among those who know, the vast majority are undergoing drug treatments. However, less than half of these have their HbA1c levels controlled. Worse scenarios were found in subgroups with high social vulnerability.

Diabetes Mellitus; Epidemiology; Awareness; Therapeutics

INTRODUCTION

Diabetes mellitus (DM) is one of the major public health problems of the twenty-first century. The number of people with DM in the world is estimated at 537 million in 2021, with a projection of 643 million for 2030 and 783 million for 2045 ¹1. International Diabetes Federation. IDF Diabetes Atlas . 10th ed. Brussels: International Diabetes Federation; 2021. . Approximately 50% of DM cases do not receive timely diagnosis ²2. Saeedi P, Petersohn I, Salpea P, Malanda B, Karuranga S, Unwin N, et al. Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: results from the International Diabetes Federation Diabetes Atlas, 9 th edition. Diabetes Res Clin Pract. 2019 Nov;157:107843. https://doi.org/10.1016/j.diabres.2019.107843
https://doi.org/10.1016/j.diabres.2019.1... , and about 90% of cases are type 2 ¹1. International Diabetes Federation. IDF Diabetes Atlas . 10th ed. Brussels: International Diabetes Federation; 2021. . A study conducted with glycated hemoglobin (HbA1c) data obtained from the National Health Survey (PNS) showed a 6.6% prevalence of DM (HbA1c ≥ 6.5%) in the Brazilian population ³3. Malta DC, Duncan BB, Schmidt MI, Machado IE, Silva AG, Bernal RTI, et al. Prevalência de diabetes mellitus determinada pela hemoglobina glicada na população adulta brasileira, Pesquisa Nacional de Saúde. Rev Bras Epidemiol. 2019; 22(Suppl 2):E190006. https://doi.org/10.1590/1980-549720190006.supl.2
https://doi.org/10.1590/1980-54972019000... . Additionally, self-reported DM increased from 6.2% in 2013 to 7.7% in 2019 ⁴4. Malta DC, Ribeiro EG, Gomes CS, Alves FTA, Stopa SR, Sardinha LMV, et al. Indicadores da linha de cuidado de pessoas com diabetes no Brasil: Pesquisa Nacional de Saúde 2013 e 2019. Epidemiol Serv Saude. 2022;31(spe1):e2021382. https://doi.org/10.1590/SS2237-9622202200011.especial
https://doi.org/10.1590/SS2237-962220220... . In 2021, the Relatório de Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico (Surveillance System for Risk and Protective Factors for Chronic Diseases by Telephone Survey – Vigitel) presented a 9.1% prevalence of self-reported DM in the Brazilian adult population ⁵5. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Vigilância de Doenças e Agravos não Transmissíveis e Promoção da Saúde. Vigitel Brasil 2021: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2021. Brasília, DF: Ministério da Saúde, 2021. . Therefore, estimates of the magnitude of DM in the Brazilian population in general ³3. Malta DC, Duncan BB, Schmidt MI, Machado IE, Silva AG, Bernal RTI, et al. Prevalência de diabetes mellitus determinada pela hemoglobina glicada na população adulta brasileira, Pesquisa Nacional de Saúde. Rev Bras Epidemiol. 2019; 22(Suppl 2):E190006. https://doi.org/10.1590/1980-549720190006.supl.2
https://doi.org/10.1590/1980-54972019000... , ⁶6. Schmidt MI, Hoffmann JF, Diniz MFS, Lotufo PA, Griep RH, Bensenor IM, et al. High prevalence of diabetes and intermediate hyperglycemia - The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Diabetol Metab Syndr. 2014 Nov;6(123):123. https://doi.org/10.1186/1758-5996-6-123
https://doi.org/10.1186/1758-5996-6-123... , ⁷7. Fernandes JR, Ogurtsova K, Linnenkamp U, Guariguata L, Seuring T, Zhang P, et al. IDF Diabetes Atlas estimates of 2014 global health expenditures on diabetes. Diabetes Res Clin Pract. 2016 Jul;117:48-54. https://doi.org/10.1016/j.diabres.2016.04.016
https://doi.org/10.1016/j.diabres.2016.0... , and in specific groups, such as men, black and mixed people, people with average or complete educational levels, and obese people, are well defined ⁸8. Irazola V, Rubinstein A, Bazzano L, Calandrelli M, Chung-Shiuan C, Elorriaga N, et al. Prevalence, awareness, treatment and control of diabetes and impaired fasting glucose in the Southern Cone of Latin America. PLoS One. 2017 Sep;12(9):e0183953. https://doi.org/10.1371/journal.pone.0183953
https://doi.org/10.1371/journal.pone.018... .

Population studies in Latin America showed that the lack of knowledge on the DM diagnosis ranged from 10.3% to 50%, being higher in Guatemala (48.8%), Uruguay (48.7%), and Nicaragua (43.3%), and lower in Colombia (23.5%), South American meridian countries (20.2%), and Costa Rica (10.3–28.4%) ¹⁰10. Avilés-Santa ML, Monroig-Rivera A, Soto-Soto A, Lindberg NM. Current state of diabetes mellitus prevalence, awareness, treatment, and control in Latin America: challenges and innovative solutions to improve health outcomes across the continent. Curr Diab Rep. 2020 Oct;20(11):62. https://doi.org/10.1007/s11892-020-01341-9
https://doi.org/10.1007/s11892-020-01341... . The same study also showed that the treatment of this disease in patients ranged from 52.6% to 99%. The prevalence of DM control (HbA1c levels < 7%) ranged from 3.5% to 7.5% ¹⁰10. Avilés-Santa ML, Monroig-Rivera A, Soto-Soto A, Lindberg NM. Current state of diabetes mellitus prevalence, awareness, treatment, and control in Latin America: challenges and innovative solutions to improve health outcomes across the continent. Curr Diab Rep. 2020 Oct;20(11):62. https://doi.org/10.1007/s11892-020-01341-9
https://doi.org/10.1007/s11892-020-01341... . However, some studies performed this verification by means of fasting glycemia or casual glycemia and showed a 31.4% to 61.4% variation ¹⁰10. Avilés-Santa ML, Monroig-Rivera A, Soto-Soto A, Lindberg NM. Current state of diabetes mellitus prevalence, awareness, treatment, and control in Latin America: challenges and innovative solutions to improve health outcomes across the continent. Curr Diab Rep. 2020 Oct;20(11):62. https://doi.org/10.1007/s11892-020-01341-9
https://doi.org/10.1007/s11892-020-01341... . Specifically in Brazil, a study conducted in the 1990s ¹¹11. Malerbi DA, Franco LJ; The Brazilian Cooperative Group on the Study of Diabetes Prevalence. Multicenter study of the prevalence of diabetes mellitus and impaired glucose tolerance in the urban Brazilian population aged 30-69 yr. Diabetes Care. 1992 Nov;15(11):1509-16. https://doi.org/10.2337/diacare.15.11.1509
https://doi.org/10.2337/diacare.15.11.15... , and, more recently, the Estudo Longitudinal de Saúde do Adulto (ELSA) ⁶6. Schmidt MI, Hoffmann JF, Diniz MFS, Lotufo PA, Griep RH, Bensenor IM, et al. High prevalence of diabetes and intermediate hyperglycemia - The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Diabetol Metab Syndr. 2014 Nov;6(123):123. https://doi.org/10.1186/1758-5996-6-123
https://doi.org/10.1186/1758-5996-6-123... identified about 50% of ignorance of the diagnosis.

DM control on a populational level requires an articulation of actions directed to the prevention, detection, and control of the pathology, including a partnership between civil society and government agencies ⁷7. Fernandes JR, Ogurtsova K, Linnenkamp U, Guariguata L, Seuring T, Zhang P, et al. IDF Diabetes Atlas estimates of 2014 global health expenditures on diabetes. Diabetes Res Clin Pract. 2016 Jul;117:48-54. https://doi.org/10.1016/j.diabres.2016.04.016
https://doi.org/10.1016/j.diabres.2016.0... . Thus, it is possible to highlight the need to estimate disease control parameters in population subgroups, such as the ability to detect/know the diagnosis, treatment, and control, in addition to its prevalence, as has been discussed internationally ⁸8. Irazola V, Rubinstein A, Bazzano L, Calandrelli M, Chung-Shiuan C, Elorriaga N, et al. Prevalence, awareness, treatment and control of diabetes and impaired fasting glucose in the Southern Cone of Latin America. PLoS One. 2017 Sep;12(9):e0183953. https://doi.org/10.1371/journal.pone.0183953
https://doi.org/10.1371/journal.pone.018... , ⁹9. Shirani S, Kelishadi R, Sarrafzadegan N, Khosravi A, Sadri G, Amani A, et al. Awareness, treatment and control of hypertension, dyslipidaemia and diabetes mellitus in an Iranian population: the IHHP study. East Mediterr Health J. 2009;15(6):1455–63. .

Inadequate DM control can lead to several complications, such as blindness, chronic kidney disease, and high risk of cardiovascular diseases, and all these outcomes contribute to the increase of health service costs. DM is a manageable disease in primary health care (PHC) services, since public health systems have effective strategies for its early detection, treatment, and control. In Brazil, a study with a regional sample showed worse levels of glycemic control in patients treated by the public health service ¹²12. Panarotto D, Träsel HA, Oliveira MS, Gravina LB, Teles AR. Controle glicêmico de pacientes diabéticos tipo 2 nos serviços público e privado de Saúde. Arq Bras Endocrinol Metabol. 2009 Aug;53(6):733-40. https://doi.org/10.1590/S0004-27302009000600007
https://doi.org/10.1590/S0004-2730200900... . A study developed in Latin America’s private health services, including the Brazilian health service, showed that blood glucose levels are less controlled in patients with type 2 DM (DM2) ¹³13. Lopez Stewart G, Tambascia M, Rosas Guzmán J, Etchegoyen F, Ortega Carrión J, Artemenko S. Control of type 2 diabetes mellitus among general practitioners in private practice in nine countries of Latin America. Rev Panam Salud Publica. 2007 Jul;22(1):12-20. https://doi.org/10.1590/S1020-49892007000600002
https://doi.org/10.1590/S1020-4989200700... .

The reliable assessment of the magnitude and treatment of population DM is only possible with representative studies of the Brazilian population and diagnostic techniques of high sensitivity and specificity. Despite the specific data on DM treatment and control in Brazil, the evaluation of these parameters in the population needs to advance. Thus, the aim of this study is to estimate the proportions of awareness, treatment, and control in a representative sample of the Brazilian adult population.

METHODS

Study Design and Population

The National Health Survey ( Pesquisa Nacional de Saúde – PNS) was conducted in 2013 and extended until 2015 for the collection of biological material. Details about the sampling methodology of the PNS are presented in previous publications ¹⁴14. Szwarcwald CL, Malta DC, Souza Júnior PR, Almeida WS, Damacena GN, Pereira CA, et al. Exames laboratoriais da Pesquisa Nacional de Saúde: metodologia de amostragem, coleta e análise dos dados. Rev Bras Epidemiol. 2019;22 Suppl 02:e190004. https://doi.org/10.1590/1980-549720190004.supl.2.
https://doi.org/10.1590/1980-54972019000... . This is a survey with cluster sampling in three stages: the census tracts correspond to a fixed number of private households, and for each household a participant aged 18 years or older is randomly selected. The total number of households visited was 81,167. Of these, 69,994 contained residents. At the end, 64,384 home interviews and 60,202 individual interviews were conducted.

The collection of biological material was performed in a subsample with 25% of the census tracts surveyed, totaling 8,952 individuals, who answered the basic questionnaire and were the subjects of our study. To obtain population estimates, the last phase included the weight of post-stratification according to sex, age, education, and region to effectively represent the adult population of the country ³3. Malta DC, Duncan BB, Schmidt MI, Machado IE, Silva AG, Bernal RTI, et al. Prevalência de diabetes mellitus determinada pela hemoglobina glicada na população adulta brasileira, Pesquisa Nacional de Saúde. Rev Bras Epidemiol. 2019; 22(Suppl 2):E190006. https://doi.org/10.1590/1980-549720190006.supl.2
https://doi.org/10.1590/1980-54972019000... .

Interviews were conducted through the application of a questionnaire, which took place at the participants’ home, by trained interviewers. Sociodemographic data, personal medical history and lifestyle variables were recorded. It also included aspects related to diabetes diagnoses and treatment, measurements of weight, height, waist circumference and blood pressure, in residents aged 18 years or more in each randomly selected household.

Biological Material Collection

Blood material (7 ml) was collected at any time of the day, without fasting ¹⁴14. Szwarcwald CL, Malta DC, Souza Júnior PR, Almeida WS, Damacena GN, Pereira CA, et al. Exames laboratoriais da Pesquisa Nacional de Saúde: metodologia de amostragem, coleta e análise dos dados. Rev Bras Epidemiol. 2019;22 Suppl 02:e190004. https://doi.org/10.1590/1980-549720190004.supl.2.
https://doi.org/10.1590/1980-54972019000... . HbA1c was determined from high-performance liquid chromatography (HPLC) of a sample stored in a tube containing ethylenediaminetetraacetic acid (EDTA). It is worth mentioning that the full described step was performed by laboratories certified by the National Glycohemoglobin Standardization Program ¹⁴14. Szwarcwald CL, Malta DC, Souza Júnior PR, Almeida WS, Damacena GN, Pereira CA, et al. Exames laboratoriais da Pesquisa Nacional de Saúde: metodologia de amostragem, coleta e análise dos dados. Rev Bras Epidemiol. 2019;22 Suppl 02:e190004. https://doi.org/10.1590/1980-549720190004.supl.2.
https://doi.org/10.1590/1980-54972019000... .

Study Variables

The diabetes diagnosis was defined using HbA1c levels ≥ 6.5% or levels of medication for the disease. Awareness of the diagnosis was defined by the proportion of participants who reported using antidiabetic medication or having received the diagnosis from a health professional. The proportion of participants in treatment was obtained from information on the use of diabetes medications or insulin. The control was defined by two criteria: the proportion of participants who presented HbA1c values < 6.5%, and the proportion of participants with HbA1c < 7% ² ( Figure 1 ). These limits were defined despite the lack of consensus, and recent evidence indicate that the 7% target is related to the prevention of chronic complications ¹⁵15. Sociedade Brasileira de Diabetes. Diretrizes da Sociedade Brasileira de Diabetes 2019–2020: gestão biênio 2018–2019. São Paulo: Clannad; 2019. . This cutoff point should also be further relaxed for individuals at risk of hypoglycemia, such as older adults, being HbA1c < 7.5% in these cases ¹⁵15. Sociedade Brasileira de Diabetes. Diretrizes da Sociedade Brasileira de Diabetes 2019–2020: gestão biênio 2018–2019. São Paulo: Clannad; 2019. .

The sociodemographic variables used were: sex (male and female); age group (18 to 30, 31 to 40, 41 to 50, 51 to 59 and ≥ 60); race/skin color (white, black, yellow/indigenous, and mixed); schooling (no education until complete elementary school, incomplete and complete high school, or incomplete and complete higher education); region of residence (North, Northeast, Southeast, South and Midwest); private health plan (has health insurance or does not have health insurance); receipt of Bolsa Família (receives Bolsa Família or does not receive Bolsa Família ) and self-perceived health (good/excellent, regular, poor, or very poor).

Data Analysis

The prevalence of DM was calculated according to the diagnostic criteria defined in this study. Next, estimates of the proportion of other outcomes of interest (DM awareness, treatment, and control) and their respective 95% confidence intervals were calculated. These proportions were also estimated according to sociodemographic characteristics, and Pearson’s chi-square test was used to analyze the differences in the proportions of outcomes between the groups. All estimates were calculated in the Stata 14.0 software survey module.

Ethical Aspects

This study used a secondary, publicly available, and free of charge database, respecting the participants’ confidentiality, not requiring prior approval by the Ethics and Research Committee. The PNS was approved by the National Research Ethics Commission, under CAAE No. 10853812.7.0000.0008, and complies with all ethical precepts, in accordance with the recommendations for research with human beings of Resolution No. 466/12.

RESULTS

The adult population was composed mostly of women (52.1%), of the white race/skin color (47.8%), with low schooling (49.3%), without health insurance (70.3%), non-beneficiaries of the Bolsa Família program (90.6%), with excellent self-perceived health (64.9%), and mainly from the Southeast region (44.3%) ( Table 1 ). DM prevalence of DM was estimated in 8.6% (95%CI: 7.8–9.3) of this population. Most people with DM were female (60.7%), aged over 60 years (54.3%), with low schooling (67.2%), poor self-perceived health (59.5%), and lived in the Southeast region of the country (49.3%).

We estimated that 68.2% (95%CI: 63.9–72.3) of people with diabetes were aware of their diagnosis and, of these, 92.2% (95%CI: 88.6–94.7) were on medication treatments. We estimated that 35.9% (95%CI: 30.5–41.6) of people had HbA1c levels considered normal (< 6.5%) and 48.1% (95%CI: 42.2–53.9) had HbA1c levels below 7%, that is, with normalized or controlled glucose homeostasis, among those who received some type of pharmacological treatment ( Figure 2 ).

The proportion of DM awareness was of 41.7% (95%CI: 25.6–60.0) in 18 to 39 years age group, 65.7% (95%CI: 60.6–70.5) among participants without health insurance, 47.5% (95%CI: 31.6–64.0) in the group which received Bolsa Família , 51.8% (95%CI: 44.0–56.0) among those with good/excellent self-perceived health, and 51.5% (95%CI: 42.9–60.0) in residents of the North region of the country ( Table 2 ). The same table shows that the proportion of drug treatment was lower in males (88%) (95%CI: 80.0–93.1), those among the 40 to 49 years age group (84.6%) (95%CI: 61.6–94.9), and those who did not have health insurance (89.9%) (95%CI: 85.0–93.4).

Table 2 also shows the proportions of DM patients who are under control using two cutoff points: HbA1c < 6.5% was 35.8%, and HbA1c < 7% was 48.1%. There was also a lower control, from the first cutoff point, in males (35.7%) (95%CI: 26.8–45.7) and those who reported poor self-perceived health (30.4%) (95%CI: 24.7–36.9). Regarding the second cutoff point, a lower control was observed in males (43.6%) (95%CI: 33.9–53.8), in those with incomplete/complete secondary education (44.8%) (95%CI: 31.7–58.6), and those who reported poor self-perceived health (43.1%) (95%CI: 36.6–49.5).

DISCUSSION

In this study, we estimate that approximately one in ten Brazilians has a diabetes diagnosis and, of these, 68.2% are aware of their diagnosis. In addition, most diabetics are undergoing drug treatment, and less than half of these have their HbA1c levels below 6.5%, that is, controlled. When considering more flexible glycemic control goals,we observed that 48.1% of the adult population has HbA1c < 7%, and 65.7% of older adults have HbA1c < 7.5%.

The highest DM prevalence was in the group over 60 years of age, who declared themselves to be of the yellow/indigenous race/skin color, with low schooling, with poor self-perceived health, and in Brazil’s Midwest and Southeast populations. The proportions of DM awareness, control, and treatment were lower in men aged 18 to 39 years, individuals with low education, without health insurance, and beneficiaries of the Bolsa Família program.

The high proportions of participants who are unaware of their diagnosis are, in this study, concentrated in groups of low socioeconomic levels, participants of the B olsa Família program, and residents of the northern region of the country, as another study already observed ¹⁶16. Malta DC, Bernal RT, Carvalho QH, Pell JP, Dundas R, Leyland A, et al. Mulheres e avaliação das desigualdades na distribuição de fatores de risco para Doenças Crônicas Não Transmissíveis (DCNT), Vigitel 2016–2017. Rev Bras Epidemiol. 2020;23:e200058. https://doi.org/10.1590/1980-549720200058
https://doi.org/10.1590/1980-54972020005... .

An additional aspect, which was shown in a recent study, is that populations with few socioeconomic resources also have high rates of smoking, overweight and obesity prevalence, low consumption of fruits and vegetables, and high consumption of sugar-sweetened beverages, and, in women, low access to cervical and breast cancer screening programs ¹⁶16. Malta DC, Bernal RT, Carvalho QH, Pell JP, Dundas R, Leyland A, et al. Mulheres e avaliação das desigualdades na distribuição de fatores de risco para Doenças Crônicas Não Transmissíveis (DCNT), Vigitel 2016–2017. Rev Bras Epidemiol. 2020;23:e200058. https://doi.org/10.1590/1980-549720200058
https://doi.org/10.1590/1980-54972020005... .

Strategies, such as the National Campaign for DM Detection, which reached more than 20 million Unified Health System (SUS) users aged over 40 years ¹⁷17. Ministério da Saúde (BR), Organização Pan-Americana da Saúde. Avaliação do Plano de Reorganização da Atenção à Hipertensão Arterial e ao Diabetes Mellitus no Brasil. Brasília, DF: Ministério da Saúde; 2004. (Série C. Projetos, programas e relatórios). , should be reissued. However, strategies for the use of light care, low cost and wide accessibility technology for the Brazilian population may be necessary.

The Brazilian population is certainly not far from global prevalence estimates. A recent study shows that approximately 50% of adult diabetics are not aware of their diagnosis, and that, of these, 84.3% are living in developing countries ¹⁸18. Beagley J, Guariguata L, Weil C, Motala AA. Global estimates of undiagnosed diabetes in adults. Diabetes Res Clin Pract. 2014 Feb;103(2):150-60. https://doi.org/10.1016/j.diabres.2013.11.001
https://doi.org/10.1016/j.diabres.2013.1... . A low-cost, non-invasive, and easy-to-apply alternative would be the use of the Finnish Diabetes Risk Score (FINDRISC), which measures the risk of DM2 development in adults. This strategy has had its validity demonstrated at a national level ¹⁹19. Barim EM, McLellan KC, Ribeiro RS, Carvalho JA, Lindström J, Tuomilehto J, et al. Translation and cultural adaptation into Brazilian Portuguese of the Finnish Diabetes Risk Score (FINDRISC) and reliability assessment. Rev Bras Epidemiol. 2020 Jun;23:e200060. https://doi.org/10.1590/1980-549720200060
https://doi.org/10.1590/1980-54972020006... .

Low prevalence of controlled diabetes, measured by glycated hemoglobin levels (< 6.5%), was present in the low schooling and beneficiaries of the Bolsa Família program groups. These findings reinforce the link between social vulnerability and low access to effective disease control, corroborating findings of other studies ²⁰20. Malta DC, Bernal RT, Gomes CS, Cardoso LS, Lima MG, Barros MB. Inequalities in the use of health services by adults and elderly people with and without noncommunicable diseases in Brazil, 2019 National Health Survey. Rev Bras Epidemiol. 2021 Dec;24 suppl 2:e210003. https://doi.org/10.1590/1980-549720210003.supl.2
https://doi.org/10.1590/1980-54972021000... .

Estimates using data from the PNS 2019 showed that younger people had lower medication consumption ³3. Malta DC, Duncan BB, Schmidt MI, Machado IE, Silva AG, Bernal RTI, et al. Prevalência de diabetes mellitus determinada pela hemoglobina glicada na população adulta brasileira, Pesquisa Nacional de Saúde. Rev Bras Epidemiol. 2019; 22(Suppl 2):E190006. https://doi.org/10.1590/1980-549720190006.supl.2
https://doi.org/10.1590/1980-54972019000... , which can be justified by the lower severity of the pathology, and it is also possible to favor management through non-pharmacological measures, such as encouraging physical activity and healthy eating. In addition, type 1 DM (DM1), not identified in this study, may present lower glycemic control, due to the severity of the disease, as well as its resistance to medication use ²¹21. Gomes MB, Coral M, Cobas RA, Dib SA, Canani LH, Nery M, et al. Prevalence of adults with type 1 diabetes who meet the goals of care in daily clinical practice: a nationwide multicenter study in Brazil. Diabetes Res Clin Pract. 2012 Jul;97(1):63-70. https://doi.org/10.1016/j.diabres.2012.02.008
https://doi.org/10.1016/j.diabres.2012.0... .

We were also able to identify a higher frequency of hospitalization in young people aged 18 to 29 years, which is understandable given the higher prevalence of DM1 in young adults, the acute symptoms of the disease and the non-adaptation to new care and lower adherence to caregiver practices ⁴4. Malta DC, Ribeiro EG, Gomes CS, Alves FTA, Stopa SR, Sardinha LMV, et al. Indicadores da linha de cuidado de pessoas com diabetes no Brasil: Pesquisa Nacional de Saúde 2013 e 2019. Epidemiol Serv Saude. 2022;31(spe1):e2021382. https://doi.org/10.1590/SS2237-9622202200011.especial
https://doi.org/10.1590/SS2237-962220220... . Lower hospitalization due to DM or complications were identified among women, which may mean better disease control among them, which coincides with our findings ⁴4. Malta DC, Ribeiro EG, Gomes CS, Alves FTA, Stopa SR, Sardinha LMV, et al. Indicadores da linha de cuidado de pessoas com diabetes no Brasil: Pesquisa Nacional de Saúde 2013 e 2019. Epidemiol Serv Saude. 2022;31(spe1):e2021382. https://doi.org/10.1590/SS2237-9622202200011.especial
https://doi.org/10.1590/SS2237-962220220... .

The high proportion of people with diabetes in treatment estimated in this study refers to the public policies implemented to improve access to medication, through the Popular Pharmacy ( Farmácia Popular ) and Health Has No Price ( Saúde Não Tem Preço ) programs, which allow free access to these drugs in Basic Health Units and pharmacies accredited to the programs. The surveillance systems also showed that 70.3% of people diagnosed with DM obtained free oral medicines through the SUS pharmacy or the Popular Pharmacy ( Farmácia Popular ) program, and that 90% had free access to insulin ²²22. Francisco PM, Rodrigues PS, Costa KS, Tavares NU, Tierling VL, Barros MB, et al. Prevalência de diabetes em adultos e idosos, uso de medicamentos e fontes de obtenção: uma análise comparativa de 2012 e 2016. Rev Bras Epidemiol. . Notably, the National Survey on Access, Use and Promotion of the Rational Use of Medicines ( Pesquisa Nacional sobre Acesso, Utilização e Promoção do Uso Racional de Medicamentos – PNAUM), a population-based household survey, showed that 21.4% of participants paid for diabetes medication, and 78.6% got it for free ²³23. Meiners MM, Tavares NU, Guimarães LS, Bertoldi AD, Pizzol TD, Luiza VL, et al. Acesso e adesão a medicamentos entre pessoas com diabetes no Brasil: evidências da PNAUM. Rev Bras Epidemiol. 2017;20(3):445-59. https://doi.org/10.1590/1980-5497201700030008
https://doi.org/10.1590/1980-54972017000... . Still confirming these conclusions, 57.4% of the PNS 2013 participants reported obtaining drugs for diabetes via the Farmácia Popular program ²⁴24. Costa KS, Tavares NU, Mengue SS, Pereira MA, Malta DC, Silva JB. Obtenção de medicamentos para hipertensão e diabetes no Programa Farmácia Popular do Brasil: resultados da Pesquisa Nacional de Saúde, 2013. Epidemiol Serv Saude. 2016;25(1):33-44. https://doi.org/10.5123/S1679-49742016000100004
https://doi.org/10.5123/S1679-4974201600... . In this study, we do not have information to clarify whether the prevalence of participants without treatment is related to the choice of medications or to access difficulties ²⁵25. Gontijo MF, Ribeiro AQ, Klein CH, Rozenfeld S, Acurcio FA. Uso de anti-hipertensivos e antidiabéticos por idosos: inquérito em Belo Horizonte, Minas Gerais, Brasil. Cad Saude Publica. 2012 Jul;28(7):1337-46. https://doi.org/10.1590/S0102-311X2012000700012
https://doi.org/10.1590/S0102-311X201200... .

In PHC, the follow-up of patients with diabetes after diagnosis includes medical and nursing consultations, participation in diabetic groups. The number of consultations with each professional changes according to the patient’s clinical condition ²⁶26. Secretaria Municipal de Saúde e Defesa Civil (RJ). Superintendência de Atenção Primária. Guia de Referência Rápida: Diabetes Mellitus: versão profissional. / Rio de Janeiro: SMSDC, 2013 [cited 2023 Feb 2]. Available from: http://www.rio.rj.gov.br/dlstatic/10112/4446958/4111923/GuiaDM.pdf
http://www.rio.rj.gov.br/dlstatic/10112/... . It is important to emphasize, for those who are under glycemic control, the need to perform fasting glucose and HbA1c tests twice a year and, for those who are not, every three months ²⁶26. Secretaria Municipal de Saúde e Defesa Civil (RJ). Superintendência de Atenção Primária. Guia de Referência Rápida: Diabetes Mellitus: versão profissional. / Rio de Janeiro: SMSDC, 2013 [cited 2023 Feb 2]. Available from: http://www.rio.rj.gov.br/dlstatic/10112/4446958/4111923/GuiaDM.pdf
http://www.rio.rj.gov.br/dlstatic/10112/... .

The maintenance of glucose levels within the normal range is essential for coping with DM. In this study, the prevalence of control was low, not far from findings in other populations, such as those of Iranian Kurdistan (18.30%) ²⁷27. Safari–Faramani R, Rajati F, Tavakol K, Hamzeh B, Pasdar Y, Moradinazar M, Najafi F. Prevalence, awareness, treatment, control, and the associated factors of Diabetes in an Iranian Kurdish population. J Diabetes Res. 2019; 3;2019:5869206. https://doi.org/10.1155/2019/5869206
https://doi.org/10.1155/2019/5869206... , Korea (42.5%) ²⁸28. Boo S, Yoon YJ, Oh H. Evaluating the prevalence, awareness, and control of hypertension, diabetes, and dyslipidemia in Korea using the NHIS-NSC database: a cross-sectional analysis. Medicine (Baltimore). 2018 Dec;97(51):e13713. https://doi.org/10.1097/MD.0000000000013713
https://doi.org/10.1097/MD.0000000000013... , and Myanmar (40.8%) ²⁹29. Aung WP, Bjertness E, Htet AS, Stigum H, Kjøllesdal MK. Trends in Diabetes prevalence, awareness, treatment and control in Yangon Region, Myanmar, between 2004 and 2014, two cross-sectional studies. Int J Environ Res Public Health. 2019 Sep;16(18):3461. https://doi.org/10.3390/ijerph16183461
https://doi.org/10.3390/ijerph16183461... . Previous studies estimated a prevalence of 26% and 78% of glycemic level control in a population attended by public health services and in a population attended by private services, respectively, but these are local studies without national representation, which makes it difficult to compare them to our study ¹²12. Panarotto D, Träsel HA, Oliveira MS, Gravina LB, Teles AR. Controle glicêmico de pacientes diabéticos tipo 2 nos serviços público e privado de Saúde. Arq Bras Endocrinol Metabol. 2009 Aug;53(6):733-40. https://doi.org/10.1590/S0004-27302009000600007
https://doi.org/10.1590/S0004-2730200900... , ¹³13. Lopez Stewart G, Tambascia M, Rosas Guzmán J, Etchegoyen F, Ortega Carrión J, Artemenko S. Control of type 2 diabetes mellitus among general practitioners in private practice in nine countries of Latin America. Rev Panam Salud Publica. 2007 Jul;22(1):12-20. https://doi.org/10.1590/S1020-49892007000600002
https://doi.org/10.1590/S1020-4989200700... .

Failures in glycemic control may contribute to increase risks of cardiovascular diseases, nephropathies, neuropathies, retinopathies, and hospitalizations ³⁰30. Lai YR, Huang CC, Chiu WC, Liu RT, Tsai NW, Wang HC, et al. HbA1C Variability is strongly associated with the severity of cardiovascular autonomic neuropathy in patients with Type 2 Diabetes after longer diabetes duration. Front Neurosci. 2019 May;13:458. https://doi.org/10.3389/fnins.2019.00458
https://doi.org/10.3389/fnins.2019.00458... . It is noteworthy that the complexity inherent to drug therapies contributes to increase medication error risks and requires the user to have the skills to comply with the care provided by health professionals ³¹31. Nogueira M, Otuyama LJ, Rocha PA, Pinto VB. Pharmaceutical care-based interventions in type 2 diabetes mellitus: a systematic review and meta-analysis of randomized clinical trials. Einstein (Sao Paulo). 2020 Jan;18:eRW4686. https://doi.org/10.31744/einstein_journal/2020RW4686
https://doi.org/10.31744/einstein_journa... , ³²32. Chan JC, Lim LL, Wareham NJ, Shaw JE, Orchard TJ, Zhang P, et al. The Lancet Commission on diabetes: using data to transform diabetes care and patient lives. Lancet. 2021 Dec;396(10267):2019-82. https://doi.org/10.1016/S0140-6736 (20)32374-6
https://doi.org/10.1016/S0140-6736 (20)3... . The challenge of drug therapy was accompanied by the quantity of drugs in use, resulting from patients with high complexity, who used polypharmacy ³³33. Pantuzza LL, Ceccato MD, Silveira MR, Pinto IV, Reis AM. Validation and standardization of the Brazilian version of the Medication Regimen Complexity Index for older adults in primary care. Geriatr Gerontol Int. 2018 Jun;18(6):853-9. https://doi.org/10.1111/ggi.13261
https://doi.org/10.1111/ggi.13261... . The patient’s empowerment in the self-care process, health education, especially in relation to medication schedule information, and the correct use of drugs in accordance with the medical prescription, are necessary strategies to achieve disease control ³⁴34. Nanayakkara N, Pease A, Ranasinha S, Wischer N, Andrikopoulos S, Speight J, et al. Depression and diabetes distress in adults with type 2 diabetes: results from the Australian National Diabetes Audit (ANDA) 2016. Sci Rep. 2018 May;8(1):7846. https://doi.org/10.1038/s41598-018-26138-5
https://doi.org/10.1038/s41598-018-26138... .

Glycemic control is essential to decrease the risk of DM complications and cardiovascular diseases. Other important factors are the lipid profile monitoring and the appropriate treatment to achieve glycemic control. DM management in primary care follows a strategy of healthy lifestyle habit encouragement. However, in practice, the program is mostly focused on medicine supply. This work process hinders the achievement of objectives such as the recognition and dimensioning of health problems, both individually and collectively, which help more effectively in health actions/interventions, as shown in a study developed in the city of São Paulo ³⁵35. Venancio SI, Rosa TE, Bersusa AA. Atenção integral à hipertensão arterial e diabetes mellitus: implementação da Linha de Cuidado em uma Região de Saúde do estado de São Paulo, Brasil. Physis. 2016;26(1):113-35. https://doi.org/10.1590/S0103-73312016000100008
https://doi.org/10.1590/S0103-7331201600... . Studies show that there is no link between patients with DM and the actions of health professionals, corroborating for the discontinuity of treatment adherence and directly impacting its control ³⁶36. Silva JV, Mantovani MF, Kalinke LP, Ulbrich EM. Avaliação do Programa de Hipertensão Arterial e Diabetes Mellitus na visão dos usuários. Rev Bras Enferm. 2015;68(4):626-32. https://doi.org/10.1590/0034-7167.2015680408i
https://doi.org/10.1590/0034-7167.201568... .

The low DM control results identified in this study can be explained by the complexity of the management of the disease, which includes the monitoring of glycemic values, adherence to treatment and the inclusion of regular physical activity and diet changes ³⁷37. Rubin RR, Peyrot M, Kruger DF, Travis LB. Barriers to insulin injection therapy: patient and health care provider perspectives. Diabetes Educ. 2009;35(6):1014-22. https://doi.org/10.1177/0145721709345773
https://doi.org/10.1177/0145721709345773... . In this perspective, the strategies that contribute to the patient’s empowerment can help in the process of developing the adoption of new attitudes and skills, which will promote changes in habits/lifestyle and, consequently, in self-care. Clinical trials using education strategies through telephone interventions, training programs and home visits, have shown that these interventions contribute positively to an improvement of HbA1c levels results, to empowerment and self-care ³⁸38. Hernandez-Tejada MA, Campbell JA, Walker RJ, Smalls BL, Davis KS, Egede LE. Diabetes empowerment, medication adherence and self-care behaviors in adults with type 2 diabetes. Diabetes Technol Ther. 2012 Jul;14(7):630-4. https://doi.org/10.1089/dia.2011.0287
https://doi.org/10.1089/dia.2011.0287... . Home visits by community health agents (CHA) contribute to controlling and supervising treatment and improving adherence to self-care practices related to DM2 ³⁹39. Souza DA, Reis IA, Cortez DN, Afonso GS, Torres HC. Avaliação da visita domiciliar para o empoderamento do autocuidado em diabetes. Acta Paul Enferm. 2017;30(4):350–7. https://doi.org/10.1590/1982-0194201700052
https://doi.org/10.1590/1982-01942017000... .

Notably, the magnitude of harm shown may worsen as a result of the new PHC financing model in SUS ⁴⁰40. Ministério da Saúde (BR). Portaria nº 2.979, de 12 de novembro de 2019. Institui o Programa Previne Brasil, que estabelece novo modelo de financiamento de custeio da Atenção Primária à Saúde no âmbito do SUS, alterando a Portaria de Consolidação nº 6/GM/MS, de 28 de setembro de 2017. Diário Oficial União. 13 nov 2019. , called Prevent Brazil ( Previne Brasil ), because it only strengthens biomedical strategies, which could lead to delays in DM detection and worsen and decrease control prevalence. In addition, it is worth pointing out that the effects generated by the covid-19 pandemic may, in the short term, affect the performance of care provided to chronic diseases, worsening control and detection levels of the disease ⁴¹41. World Health Organization. NCD Department. Rapid assessment of service delivery for noncommunicable diseases (NCDs) during the COVID–19 pandemic: final results. Geneva: World Health Organization; 2020. .

A limitation of this study is the lack of data regarding the medication used, its time of use, and the adherence to treatment, which was limited to recording only the use of antidiabetic drugs and/or insulin injections. Non-pharmacological measures are also necessary for glycemic control, and they were not evaluated in this study. These data would allow a better understanding of the low performance of glycemic level control found in the Brazilian population, despite the wide access to medication and treatment. However, the use of population-based data and national representativeness constitutes adequate external validity.

We highlight that the measurement of HbA1c levels collected from venous and non-capillary blood was used, which is considered the gold standard for detecting the disease. The lack of consensus to define the cutoff point of HbA1c in disease control hinders the process of evaluation and monitoring of DM. Therefore, this study chose to work with two cutoff points.

Another limitation is the non-distinction between the DM types (DM1 or DM2). This is an unprecedented population study that uses laboratory data with representativeness of the Brazilian population to estimate DM awareness, treatment, and control, which are fundamental aspects to help public health programs cope with the disease.

The proportion of DM awareness in the Brazilian population was estimated at 68%, and of these, 92% were undergoing drug treatment. Adequate control was estimated at 36%, considering the strictest criterion (HbA1c < 6.5%). Some population subgroups, such as those who do not have health insurance, those who reported having poor self-perceived health, and beneficiaries of the Bolsa Família program, presented worse performance regarding awareness of the disease. The data from this study may contribute to strengthen public policies that aim to promote healthy lifestyles. The implementation of innovative strategies to assist in DM control is fundamental to face the disease burden attributed to DM in Brazil.

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