Abstract

This study aims to analyze the prevalence of self-reported diabetes and its associated factors in the Brazilian adult population. It is a cross-sectional study using the 2019 National Health Survey. Prevalence and crude prevalence ratios (PRc) and adjusted prevalence ratios (PRa) of self-reported diabetes were estimated, with confidence intervals (95% CI), using Poisson regression. In the 82,349 adults, the prevalence of self-reported diabetes was 7.7%. Positively associated factors were: advanced age with greater association after 60 years (PRa 24.87; 95%CI 15.78-39.18); living in the Northeast (PRa 1.16; 95%CI 1.04-1.29), Southeast (PRa 1.27; 95% CI 1.14-1.43), South (PRa 1.18; 95%CI 1, 05-1.34), and Midwest (PRa 1.21; 95%CI 1.06-1.38); being a former smoker (PRa 1.17; 95%CI 1.09-1.27); self-assessment of regular health (PRa 2.41; 95%CI 2.21-2.64), bad/very bad (PRa 3.45; 95%CI 3.06-3.88); having heart disease (PRa 1.81; 95%CI 1.64-2.00), hypertension (PRa 2.84; 95%CI 2.60-3.69), high cholesterol (PRa 2.22; 95%CI 2.05-2.41), overweight (PRa 1.49; 95%CI 1.36-1.64), and obesity (PRa 2.25; 95%CI 2.05-2.47). It could be concluded that diabetes in Brazilian adults is associated with sociodemographic factors, aging, lifestyle, and morbidities. These results can guide public policies for the prevention and control of disease in Brazil.

Key words:
Diabetes mellitus; Risk factors; Health surveys; Brazil

Introduction

Diabetes mellitus (DM) has a complex and multifactorial etiology, involving genetic and environmental components. It results from alterations in the production of insulin by the pancreas and/or incapacity of the organ in performing its function in the organism¹1 Sociedade Brasileira de Diabetes. Diretrizes da Sociedade Brasileira de Diabetes 2019-2020 [Internet]. 2019. [cited 2021 aug 16]. Available from: http://www.saude.ba.gov.br/wp-content/uploads/2020/02/Diretrizes-Sociedade-Brasileira-de-Diabetes-2019-2020.pdf
http://www.saude.ba.gov.br/wp-content/up... . DM evolves with micro and macrovascular complications²2 Cole JB, Florez JC. Genetics of diabetes mellitus and diabetes complications. Nat Rev Nephrol 2020; 16(7):377-390., which result in repercussions in the target organs, such as the heart, blood vessels, eyes, kidneys, and brain³3 World Health Organization (WHO). Global status report on noncommunicable diseases 2014 [Internet]. Geneva: World Health Organization; 2014. [cited 2021 aug 16]. Available from: http://www.who.int/nmh/publications/ncd-status-report-2014/en/^,44 World Health Organization (WHO). Diabetes [Internet]. Geneva: World Health Organization; 2014. [cited 2021 aug 16]. Available from: https://www.who.int/health-topics/diabetes.

Worldwide, approximately 422 million people suffer from DM, and 1.6 million annual deaths were directly attributed to DM between 1990 and 2019 (WHO, 2020). There has also been an increase in the number of deaths by DM between 1990 and 2019, going from 1,278,866 to 2,988,924, respectively. For the number of years lost due to incapacity (Disability Adjusted Life Years - DALYs), there was an increase from 28,586,671 in 1990 to 70,888,154 in 2019⁵5 Institute for Health Metrics and Evaluation. GBD Compare Data Visualization. Seattle: IHME; 2019.. In Brazil, a similar scenario was observed. DM was responsible for 43,787 deaths in 1990 and 107,760 deaths in 2019 (7.64% of the total); it caused 1,730,460 DALYs in 1990 and 3,750,735 in 2019 (5.73% of the total)⁵5 Institute for Health Metrics and Evaluation. GBD Compare Data Visualization. Seattle: IHME; 2019..

The profound regional inequalities contribute to the increase in the burden of DM, since countries with low and average income concentrate higher rates of morbimortality⁴4 World Health Organization (WHO). Diabetes [Internet]. Geneva: World Health Organization; 2014. [cited 2021 aug 16]. Available from: https://www.who.int/health-topics/diabetes. The socioeconomic and health inequalities are challenges in the DM context, since they hamper prevention, hinder access to care and treatment, and compromise the quality of life of people affected by the disease⁵5 Institute for Health Metrics and Evaluation. GBD Compare Data Visualization. Seattle: IHME; 2019.^,66 Iser BPM, Stopa SRS, Chueri PS, Szwarcwald CL, Malta DC, Monteiro HOC, Ducan BB, Schmidt MA. Self-reported diabetes prevalence in Brazil: results from National Health Survey 2013. Epidemiol Serv Saude 2015; 24(2):305-314..

It is also important to highlight the growth in the prevalence of DM in the last two decades, due to population aging and obesity, and because of unhealthy lifestyles, such as sedentarism and unhealthy diets⁴4 World Health Organization (WHO). Diabetes [Internet]. Geneva: World Health Organization; 2014. [cited 2021 aug 16]. Available from: https://www.who.int/health-topics/diabetes^,77 World Health Organization (WHO). Global action plan for the prevention and control of NCDs 2013-2020 [Internet]. Geneva: WHO; 2013 [cited 16 aug 21]. Available from: http://www.who.int/nmh/events/ncd_action_plan/en/.

The literature illustrates factors associated with DM, sociodemographic characteristics⁸8 Qin X, Li J, Zhang Y, Ma W, Fan F, Wang B, Xing H, Tang G, Wang X, Xu X, Huo Y. Prevalence and associated factors of diabetes and impaired fasting glucose in Chinese hypertensive adults aged 45 to 75 years. PLoS One 2012; 7(8):e42538.^,99 Bocquet V, Ruiz-Castell M, de Beaufort C, Barré J, de Rekeneire N, Michel G, Donahue RP, Kuemmerle A, Stranges S. Public health burden of pre-diabetes and diabetes in Luxembourg: finding from the 2013-2015 European Health Examination Survey. BMJ Open 2019; 9(1):e022206., family history, obesity, arterial hypertension, dyslipidemia⁹9 Bocquet V, Ruiz-Castell M, de Beaufort C, Barré J, de Rekeneire N, Michel G, Donahue RP, Kuemmerle A, Stranges S. Public health burden of pre-diabetes and diabetes in Luxembourg: finding from the 2013-2015 European Health Examination Survey. BMJ Open 2019; 9(1):e022206., insufficient physical activity, smoking, and alcohol consumption⁸8 Qin X, Li J, Zhang Y, Ma W, Fan F, Wang B, Xing H, Tang G, Wang X, Xu X, Huo Y. Prevalence and associated factors of diabetes and impaired fasting glucose in Chinese hypertensive adults aged 45 to 75 years. PLoS One 2012; 7(8):e42538..

To prevent and control DM, it is essential to have measures in place that aim to produce behavioral changes, such as an increase in the consumption of natural foods (fruit, vegetables, and grains), a reduction in the consumption of ultra-processed foods, a reduction in the intake of sugary drinks and alcohol, an increase in physical activity, weight control, and quitting smoking¹⁰10 Ardisson Korat AV, Willett WC, Hu FB. Diet, lifestyle, and genetic risk factors for type 2 diabetes: a review from the Nurses' Health Study, Nurses' Health Study 2, and Health Professionals' Follow-up Study. Curr Nutr Rep 2014; 3(4):345-354.^,1111 Oliveira JEP, Vencio S. Diretrizes da Sociedade Brasileira de Diabetes, 2013-2014 [Internet]. Sociedade Brasileira de Diabetes; 2014. [acessado 2021 jul 16]. Disponível em: http://www.sgc.goias.gov.br/upload/arquivos/2014-05/diretrizessbd-2014.pdf
http://www.sgc.goias.gov.br/upload/arqui... .

Although the gold standard for DM population monitoring is estimated by laboratory data¹²12 Malta DC, Duncan BB, Schmidt MI, Machado IE, Silva AG, Bernal RTI, Pereira CA, Damacena GN, Stopa SR, Rosenfeld LG, Szwarcwald CL. Prevalência de diabetes mellitus determinada pela hemoglobina glicada na população adulta brasileira, Pesquisa Nacional de Saúde. Rev Bras Epidemiol 2019; 22(Supl. 2):e190006.SUPL.2., health inquiries using self-reported measurements are also useful in the identification of DM prevalence, since they provide agility in terms of obtaining and publishing data, and have lower economic costs¹²12 Malta DC, Duncan BB, Schmidt MI, Machado IE, Silva AG, Bernal RTI, Pereira CA, Damacena GN, Stopa SR, Rosenfeld LG, Szwarcwald CL. Prevalência de diabetes mellitus determinada pela hemoglobina glicada na população adulta brasileira, Pesquisa Nacional de Saúde. Rev Bras Epidemiol 2019; 22(Supl. 2):e190006.SUPL.2., contributing for better surveillance actions¹³13 Keel S, Foreman J, Xie J, van Wijngaarden P, Taylor HR, Dirani M. The Prevalence of self-reported diabetes in the Australian National Eye Health Survey. PLoS One 2017; 12(1):e0169211.. Considering the negative repercussions of DM on health, this study shows progress, as it identifies, in an unprecedented manner, the populational prevalence of self-reported DM and its associated factors, according to the 2019 National Health Survey (PNS, in Portuguese). It is important to mention that the penultimate edition of the PNS (2013) estimated the self-reported prevalence of DM in 6.2%⁶6 Iser BPM, Stopa SRS, Chueri PS, Szwarcwald CL, Malta DC, Monteiro HOC, Ducan BB, Schmidt MA. Self-reported diabetes prevalence in Brazil: results from National Health Survey 2013. Epidemiol Serv Saude 2015; 24(2):305-314.. Considering the population growth¹1 Sociedade Brasileira de Diabetes. Diretrizes da Sociedade Brasileira de Diabetes 2019-2020 [Internet]. 2019. [cited 2021 aug 16]. Available from: http://www.saude.ba.gov.br/wp-content/uploads/2020/02/Diretrizes-Sociedade-Brasileira-de-Diabetes-2019-2020.pdf
http://www.saude.ba.gov.br/wp-content/up... ^,33 World Health Organization (WHO). Global status report on noncommunicable diseases 2014 [Internet]. Geneva: World Health Organization; 2014. [cited 2021 aug 16]. Available from: http://www.who.int/nmh/publications/ncd-status-report-2014/en/, it is important to know the current scenario of this condition within the country, in accordance with available data. Therefore, this study may contribute to the formulation of public policies and actions toward the control and prevention of DM¹⁴14 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa nacional de saúde: 2019: percepção do estado de saúde, estilos de vida, doenças crônicas e saúde bucal: Brasil e grandes regiões. Rio de Janeiro: IBGE; 2020..

Hence, the current study aimed to analyze the prevalence of self-reported DM and the factors associated with it, among sociodemographic characteristics, lifestyles, and health conditions within the Brazilian adult population.

Methods

This is a cross-sectional study with data from the 2019 PNS, conducted between August 2019 and March 2020. The PNS is the broadest national inquiry concerning health in the country, conducted by the Brazilian Institute of Geography and Statistics (IBGE) in partnership with the Ministry of Health¹⁴14 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa nacional de saúde: 2019: percepção do estado de saúde, estilos de vida, doenças crônicas e saúde bucal: Brasil e grandes regiões. Rio de Janeiro: IBGE; 2020.^,1515 Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, Sardinha LMV, Macário EM. Pesquisa Nacional de Saúde 2019: histórico, métodos e perspectivas. Epidemiol Serv Saude 2020; 29(5):e2020315..

The PNS uses sampling by conglomerates in three selection stages: census sectors (primary units); homes (secondary units), and residents older than 15 years of age (tertiary units). In 2019, in the third selection stage, the residents were selected randomly among those who were 15 years of age and older, based on the list of residents obtained at the time of the interview¹⁵15 Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, Sardinha LMV, Macário EM. Pesquisa Nacional de Saúde 2019: histórico, métodos e perspectivas. Epidemiol Serv Saude 2020; 29(5):e2020315..

To calculate the sample size, the average values and variances were taken into consideration, assuming a “no response” rate of 20%. In 2019, there were 108,525 homes in the sample, and data was collected from 94,114 of these⁵5 Institute for Health Metrics and Evaluation. GBD Compare Data Visualization. Seattle: IHME; 2019.. In the current study, the analyses were done only among residents who were 18 years of age or older, including 82,349 individuals. The 2019 PNS adopted a complex sample design, and therefore weights of post-stratification sampling were adopted for selected homes and residents, aimed at correcting losses by “no response” and adjusting the totals for the Brazilian population. Further details about the methodology of the 2019 PNS can be found in specific publications¹⁴14 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa nacional de saúde: 2019: percepção do estado de saúde, estilos de vida, doenças crônicas e saúde bucal: Brasil e grandes regiões. Rio de Janeiro: IBGE; 2020.^,1515 Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, Sardinha LMV, Macário EM. Pesquisa Nacional de Saúde 2019: histórico, métodos e perspectivas. Epidemiol Serv Saude 2020; 29(5):e2020315..

In this study, to construct the variables, questions were used from the questionnaire modules of: identification; characteristics of the residents (C); characteristics of the education level of the residents (D); characteristics of work (E), health insurance coverage (I); perception of the state of health (N); lifestyles (P); and chronic diseases (Q)¹⁴14 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa nacional de saúde: 2019: percepção do estado de saúde, estilos de vida, doenças crônicas e saúde bucal: Brasil e grandes regiões. Rio de Janeiro: IBGE; 2020..

The outcome variable was the self-reported diagnosis of diabetes, evaluated by question Q30a: “Has a doctor ever told you that you have diabetes?” A diagnosis of diabetes was considered when the adults answered “yes”, in addition to verifying, in the case of women, those who responded “no” to the question (Q30b) about gestational diabetes (Did this diabetes only occur during a period of your pregnancy?) The indicator was calculated by: numerator/denominator x 100 (numerator: man: Q30a = 1; woman: Q30a = 1 and Q30b = 2; denominator: number of people interviewed (C8 ≥ 18 years of age).

To support and verify the association, studies present in the literature were considered⁸8 Qin X, Li J, Zhang Y, Ma W, Fan F, Wang B, Xing H, Tang G, Wang X, Xu X, Huo Y. Prevalence and associated factors of diabetes and impaired fasting glucose in Chinese hypertensive adults aged 45 to 75 years. PLoS One 2012; 7(8):e42538.^,1818 World Health Organization (WHO). Obesity: preventing and managing the global epidemic [Internet]. Geneva: World Health Organization; 2000 [cited 2021 may 11]. Available from: https://apps.who.int/iris/handle/10665/42330, which identified the complexity of the causation network of DM, which is associated with precarious socio-economic conditions: sociodemographic characteristics (age, sex), unhealthy lifestyles, comorbidities, obesity, among other factors ⁸8 Qin X, Li J, Zhang Y, Ma W, Fan F, Wang B, Xing H, Tang G, Wang X, Xu X, Huo Y. Prevalence and associated factors of diabetes and impaired fasting glucose in Chinese hypertensive adults aged 45 to 75 years. PLoS One 2012; 7(8):e42538.^,1818 World Health Organization (WHO). Obesity: preventing and managing the global epidemic [Internet]. Geneva: World Health Organization; 2000 [cited 2021 may 11]. Available from: https://apps.who.int/iris/handle/10665/42330.Therefore, the variables used in this study were:

Sociodemographic characteristics - sex: male and female; age group in years: 18 to 24, 25 to 39, 40 to 59, 60 and older; education: no education to complete elementary education, complete elementary education to incomplete high school, complete high school to incomplete higher education, and complete higher education; race/color: white, black, and others (which correspond to yellow and indigenous); family income (per capita in number of minimum wage salaries): up to one salary, 1 to 3 minimum salaries (MS), 3 to 5 MS, 5 or more MS; region of Brazil: North, Northeast, Southeast, South, and Midwest; has health insurance: yes or no.

Lifestyle - smoking: non-smoker, former smoker, and smoker; excessive consumption of alcoholic beverages: yes or no (we considered the consumption of five or more shots at a time)¹⁴14 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa nacional de saúde: 2019: percepção do estado de saúde, estilos de vida, doenças crônicas e saúde bucal: Brasil e grandes regiões. Rio de Janeiro: IBGE; 2020.. High consumption of salt: “Considering homemade foods and industrialized foods, do you think that your salt consumption is…”, for those who responded “high” or “very high” to the question; “Consumption of foods that protect against noncommunicable diseases” (NCDs) or minimally processed, in the last 24 hours, considering whose who answered “yes” to a list of 12 foods, specifically (rice/pasta and others; potatoes/manioc/others, beans/lentils and others, beef/pork/poultry or fish; egg, lettuce/broccoli/watercress or spinach; pumpkin/carrots/sweet potatoes/okra; papaya/mango/melon or pequi; orange/banana/apple and pineapple; milk; peanut/cashews/Brazil nuts etc.; sufficient physical activity in free time: yes, no. We considered active, those who do 150 weekly minutes of moderate or light activities or 75 weekly minutes of intense, vigorous activity regardless of the number of days they are done per week¹⁶16 Malta DC, Bernal RTI, Iser BPM, Szwarcwald CL, Duncan BB, Schmidt MI. Fatores associados ao diabetes autorreferido segundo a Pesquisa Nacional de Saúde, 2013. Rev Saude Publica 2017; 51(Supl. 1):12s..

Health conditions and nutritional conditions - self-evaluation of one’s health conditions: good/very good, regular, and bad/very bad; self-reported diagnosis of hypertension: yes, no; self-reported diagnosis of high cholesterol: yes, no; nutritional condition: eutrophic, classified by body mass index (BMI) < 25 kg/m², overweight (BMI between 25 and 29 kg/m²), and obese (BMI ≥ 30kg/m²)¹⁷17 World Health Organization (WHO). Global recommendations on physical activity for health [Internet]. Geneva: WHO; 2010. [cited 2021 may 10]. Available from: https://www.who.int/publications/i/item/9789241599979. The BMI was calculated based on the report of height and weight.

In the descriptive analysis, the prevalence was estimated and was presented in prevalence (%) and 95% confidence intervals (95%CI). Adopted as an association measure was the prevalence ratio (PR) obtained by models of Poisson regression with robust variance. The crude PR (PRc) and adjusted PR (PRa) were estimated by age, education, and sex, and their respective CI were 95%. Associated factors were defined as the variables with values of p ≤ 0.05 for the adjusted analyses. The data analysis and statistical software (Stata), version 16, was used, applying the “survey” module, which considers the post-stratification weights.

The 2019 PNS was approved by the National Committee of Research Ethics from the Ministry of Health, decision number 3,529,376 (2019). Participation in the survey was voluntary, and confidentiality of information was guaranteed. The 2019 PNS data bank and the modules of the questionnaires are available for access and public use at: https://www.pns.icict.fiocruz.br/.

Results

The prevalence of the self-reported diagnosis of diabetes was 7.7% (95% CI: 7.4-8.0), which was higher for females (8.4%; 95% CI: 8.0-8.8), for those who were 60 and older (20.2%; 95% CI: 19.3-21.1), and those with a low-level education (12.9%; 95%CI: 12.3%-13.5) (Table 1).

Table 2 shows the prevalence of self-reported diabetes according to lifestyle and health conditions. It can be seen that the prevalence of diabetes is higher for former smokers (11.3%; 95%CI: 10.6-12.0), for those who responded no to excessive alcoholic beverage consumption (8.5%; 95%CI: 8.2-8.9%), those who do not have a high intake of salt (8.0%; 95%CI: 7.7-8.3), those who do not practice physical activities in their free time (8.7%; 95%CI: 8.3-9.1), and those who considered their health as regular (14.2%; 95%CI: 13.5-14.9), bad, or very bad (23.8%; 95%CI: 21.8-25.8). People with heart disease (22.5%; 95%CI: 20.5-24.5), hypertension (20.6%; 95%CI: 19.7-21.5), high cholesterol (20.8%; 95%CI: 19.5%-22.0), overweight (8.3%; 95%CI; 7.8-8.8), and obesity (12.6%; 95%CI: 11.7-13.4) showed a higher prevalence of diabetes.

In the adjusted analyses, it was verified that the higher prevalence of self-reported diabetes is associated with the female sex (PRa = 1.22; 95%CI: 1.13-1.32), increase age (25 to 39 years of age): PRa = 2.21; 95%CI: 1.36-3.61; 40 to 59 years of age: PRa = 10.54; 95% CI: 6.68-16.61; 60 or older: PRa = 24.87; 95%CI: 15.78-39.18), residing in the Northeast region (PRa = 1.16; 95%CI: 1.04-1.29), Southeast (PRa = 1.27; 95%CI: 1.14-1.43), South (PRa = 1.18; 95%CI: 1.05-1.34), and Midwest (PRa = 1.21; 95%CI: 1.06-1.38), former smokers (PRa = 1.17; 95%CI: 1.09-1.27), those who self-reported their health conditions as regular (PRa = 2.41; 95%CI: 2.21-2.64), bad or very bad (PRa = 3.45; 95%CI: 3.06-3.88), having heart disease (PRa = 1.81; 95%CI: 1.64-2.00), hypertension (PRa = 2.84; 95%CI: 2.60-3.69), high cholesterol (PRa = 2.22; 95%CI: 2.05-241), overweight (PRa = 1.49; 95%CI: 1.36-1.64), and obesity (PRa = 2.25; 95%CI: 2.05-2.47). By contrast, the lowest prevalence of diabetes is associated with having an average level education (PRa = 0.77; 95%CI: 0.70-0.86) and complete higher education (PRa = 0.58; 95%CI: 0.51-0.66), higher income (5 or more minimum wage salaries: PRa = 0.67; 95%CI: 0.58-0.78), excessive consumption of alcoholic beverages (PRa = 0.76; 95%CI: 0.66-0.88), and the practice of physical activities in one’s free time (PRa = 0.85; 95%CI: 0.77;0.93) (Table 3).

Discussion

This study identified a prevalence of self-reported diabetes of 7.7% in individuals 18 years of age and older (one in every 13 Brazilians), which represents a population group of 12.3 million people with diabetes¹⁴14 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa nacional de saúde: 2019: percepção do estado de saúde, estilos de vida, doenças crônicas e saúde bucal: Brasil e grandes regiões. Rio de Janeiro: IBGE; 2020.. DM is positively associated with females, increase in age, with the prevalence being 10-fold higher after 40 years of age and approximately 25-fold higher for individuals 60 years of age and older. Living in the Northeast, Southeast, South, and Midwest regions, being a former smoker, reporting a worse health situation, and having such comorbidities as hypertension, heart disease, cholesterol, overweight, and obesity were all factors more frequently associated with the self-reported diabetes. The negatively associated factors included having a higher-level education and income, practicing physical activities in one’s free time, and excessive alcohol intake.

The higher prevalence of self-reported diabetes among women was also identified in the 2013 PNS¹⁸18 World Health Organization (WHO). Obesity: preventing and managing the global epidemic [Internet]. Geneva: World Health Organization; 2000 [cited 2021 may 11]. Available from: https://apps.who.int/iris/handle/10665/42330 and in the laboratory edition of the PNS between 2014-2015¹²12 Malta DC, Duncan BB, Schmidt MI, Machado IE, Silva AG, Bernal RTI, Pereira CA, Damacena GN, Stopa SR, Rosenfeld LG, Szwarcwald CL. Prevalência de diabetes mellitus determinada pela hemoglobina glicada na população adulta brasileira, Pesquisa Nacional de Saúde. Rev Bras Epidemiol 2019; 22(Supl. 2):e190006.SUPL.2.. However, these results were not found in the Brazilian Longitudintal Study of Adult Health (ELSA-Brasil, in Portuguese), in which the higher prevalence rates were among men¹⁹19 Schmidt MI, Hoffmann JF, Diniz MFS, Lotufo PA, Griep RH, Bensenor IM, Mill JG, Barreto SM, Aquino EM, Duncan BB. High prevalence of diabetes and intermediate hyperglycemia - The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Diabetol Metab Syndr 2014; 6:123.. There is an implication related to the sexual hormones in the protection or in the risk factors for the development and progression of DM. Women are less likely to develop DM in comparison to men, possibly because the sexual hormones protect against the development of the condition, although diabetic comorbidities, such as cardiovascular diseases (CVD) and terminal kidney disease tend to affect women more often²⁰20 Shepard BD. Sex differences in diabetes and kidney disease: mechanisms and consequences. Am J Physiol Renal Physiol 2019; 317(2):F456-F462.. However, the loss of hormonal protection that women pass through after menopause may contribute to DM. Another possible justification for the findings in this study is in terms the search for medical services and having greater access to medical diagnoses among women, something that has already been described by data from the National Household Sample Survey (PNAD, in Portuguese)²¹21 Freitas LRS, Garcia LP. Evolução da prevalência do diabetes e deste associado à hipertensão arterial no Brasil: análise da Pesquisa Nacional por Amostra de Domicílios, 1998, 2003 e 2008. Epidemiol Serv Saude 2012; 21(1):7-19. and the inquiries conducted through the Noncommunicable Disease Risk Factor Surveillance (Vigitel, in Portuguese)²²22 Iser BPM, Yokota RTC, Sá NNB, Moura L, Malta DC. Prevalência de fatores de risco e proteção para doenças crônicas nas capitais do Brasil - principais resultados do Vigitel 2010. Cien Saude Colet 2012; 17(9):2343-2356..

The increase in age is associated with the increase in frequency of type 2 DM, especially among the elderly. Approximately one fifth of that population had the disease, due to the physiopathological mechanisms of aging, physical inactivity, poor nutrition, increase in obesity, and greater access to diagnoses²³23 American Diabetes Association. Economic costs of diabetes in the U.S. in 2012. Diabetes Care 2013; 36(4):1033-1046.. However, the study indicated that the young population, between 25 and 29 years of age, already showed a high prevalence, demonstrating that the disease has been appearing earlier. The 2013 PNS indicated a high prevalence of glycated hemoglobin abnormalities (A1c), which are indicative of diabetes (18.5% according to the criteria set forth by the American Diabetes Association and 7.5% according to the WHO criteria²⁴24 Iser BPM. Pinheiro, PC. Malta, DC. Duncan, BB. Schimidt, MI. Prevalência de pré-diabetes e hiperglicemia intermediária em adultos e fatores associados: Pesquisa Nacional de Saúde. Cien Saude Colet 2021; 26(2):531-540.), which has been explained by the increase in obesity among young people and their unhealthy lifestyles.

In relation to the sociodemographic data, we highlight the protector effect of higher education and income. Studies with data from the 2013 PNS¹⁸18 World Health Organization (WHO). Obesity: preventing and managing the global epidemic [Internet]. Geneva: World Health Organization; 2000 [cited 2021 may 11]. Available from: https://apps.who.int/iris/handle/10665/42330 and from other countries²⁵25 Chandrupatla SG, Khalid I, Muthuluri T, Dantala S, Tavares M. Diabetes and prediabetes prevalence among young and middle-aged adults in India, with an analysis of geographic differences: findings from the National Family Health Survey. Epidemiol Health 2020; 42:e2020065.^,2626 Dinca-Panaitescu S, Dinca-Panaitescu M, Bryant T, Daiski I, Pilkington B, Raphael D. Diabetes prevalence and income: results of the Canadian Community Health Survey. Health Policy 2011; 99(2):116-123. have also found a higher prevalence of DM among people with a low-level education. Those results proved that higher education and income contribute to better access to information, better health care, and better understanding of the disease and its risks, as well as the adoption of healthy nutrition habits and physical activity¹⁶16 Malta DC, Bernal RTI, Iser BPM, Szwarcwald CL, Duncan BB, Schmidt MI. Fatores associados ao diabetes autorreferido segundo a Pesquisa Nacional de Saúde, 2013. Rev Saude Publica 2017; 51(Supl. 1):12s.^,2525 Chandrupatla SG, Khalid I, Muthuluri T, Dantala S, Tavares M. Diabetes and prediabetes prevalence among young and middle-aged adults in India, with an analysis of geographic differences: findings from the National Family Health Survey. Epidemiol Health 2020; 42:e2020065.. It can be inferred that people with a higher income have greater access to health services, to the acquisition of top-quality medication with less collateral effects, and to health insurance²⁷27 Moraes SA, Freitas ICM, Gimeno SGA, Mondini L. Prevalência de diabetes mellitus e identificação de fatores associados em adultos residentes em área urbana de Ribeirão Preto, São Paulo, Brasil, 2006: Projeto OBEDIARP. Cad Saude Publica 2010; 26(5):929-941.. However, in this study, the access to health insurance did not show a difference in prevalence, indicating that the Brazilian Unified Health System (SUS, in Portuguese) has been efficient in providing access to services and diagnosis of DM in the country²⁸28 Stopa SR, Malta DC, Monteiro CN, Szwarcwald CL, Goldbaum M, Cesar CLG. Acesso e uso de serviços de saúde pela população brasileira, Pesquisa Nacional de Saúde 2013. Rev Saude Publica 2017; 51(Supl. 1):3s.. In relation to race/color, there were no significant differences in the adjusted analysis, similarly to the study conducted with data from Vigitel, which found no associations between DM and race/color²⁹29 Malta DC, Moura L, Bernal RTI. Differentials in risk factors for chronic non-communicable diseases from the race/color standpoint. Cien Saude Colet 2015; 20(3):713-725..

The North region of Brazil showed the lowest prevalence of DM in comparison to the other regions. Those results are similar to those found in a national study with laboratory data from the PNS²⁴24 Iser BPM. Pinheiro, PC. Malta, DC. Duncan, BB. Schimidt, MI. Prevalência de pré-diabetes e hiperglicemia intermediária em adultos e fatores associados: Pesquisa Nacional de Saúde. Cien Saude Colet 2021; 26(2):531-540.. Since it refers to self-reported DM, although the information from the PNS show improvements in access to and use of health services, regional differences were still observed¹⁵15 Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, Sardinha LMV, Macário EM. Pesquisa Nacional de Saúde 2019: histórico, métodos e perspectivas. Epidemiol Serv Saude 2020; 29(5):e2020315.^,1818 World Health Organization (WHO). Obesity: preventing and managing the global epidemic [Internet]. Geneva: World Health Organization; 2000 [cited 2021 may 11]. Available from: https://apps.who.int/iris/handle/10665/42330^,2424 Iser BPM. Pinheiro, PC. Malta, DC. Duncan, BB. Schimidt, MI. Prevalência de pré-diabetes e hiperglicemia intermediária em adultos e fatores associados: Pesquisa Nacional de Saúde. Cien Saude Colet 2021; 26(2):531-540.. Even though the final model was adjusted by age, the adjustment may have been insufficient to correct it, taking into consideration that the North region has the youngest population, with a lower prevalence of DM¹⁴14 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa nacional de saúde: 2019: percepção do estado de saúde, estilos de vida, doenças crônicas e saúde bucal: Brasil e grandes regiões. Rio de Janeiro: IBGE; 2020..

Considering the lifestyles, smoking is an important risk factor for cardiovascular disease, and it is associated with the aggravation of DM. Quitting smoking is the priority measure for secondary prevention¹¹11 Oliveira JEP, Vencio S. Diretrizes da Sociedade Brasileira de Diabetes, 2013-2014 [Internet]. Sociedade Brasileira de Diabetes; 2014. [acessado 2021 jul 16]. Disponível em: http://www.sgc.goias.gov.br/upload/arquivos/2014-05/diretrizessbd-2014.pdf
http://www.sgc.goias.gov.br/upload/arqui... ^,3030 Critchley JA, Capewell S. Mortality risk reduction associated with smoking cessation in patients with coronary heart disease: a systematic review. JAMA 2003; 290(1):86-97.. The current study identified an association between DM and former smokers, which could be explained by measures referring to the protocols which recommend giving up smoking when faced with the diagnosis of the disease, primarily due to the systemic vascular effects caused by tobacco¹¹11 Oliveira JEP, Vencio S. Diretrizes da Sociedade Brasileira de Diabetes, 2013-2014 [Internet]. Sociedade Brasileira de Diabetes; 2014. [acessado 2021 jul 16]. Disponível em: http://www.sgc.goias.gov.br/upload/arquivos/2014-05/diretrizessbd-2014.pdf
http://www.sgc.goias.gov.br/upload/arqui... ^,3030 Critchley JA, Capewell S. Mortality risk reduction associated with smoking cessation in patients with coronary heart disease: a systematic review. JAMA 2003; 290(1):86-97.. Moreover, another possible justification for the findings is related to the weight gain associated with quitting smoking, already identified in national¹⁸18 World Health Organization (WHO). Obesity: preventing and managing the global epidemic [Internet]. Geneva: World Health Organization; 2000 [cited 2021 may 11]. Available from: https://apps.who.int/iris/handle/10665/42330 and international³¹31 Yeh HC, Duncan BB, Schmidt MI, Wang NY, Brancati FL. Smoking, smoking cessation, and risk for type 2 diabetes mellitus: a cohort study. Ann Intern Med 2010; 152(1):10-17. literature, which also increases the risk of developing DM¹¹11 Oliveira JEP, Vencio S. Diretrizes da Sociedade Brasileira de Diabetes, 2013-2014 [Internet]. Sociedade Brasileira de Diabetes; 2014. [acessado 2021 jul 16]. Disponível em: http://www.sgc.goias.gov.br/upload/arquivos/2014-05/diretrizessbd-2014.pdf
http://www.sgc.goias.gov.br/upload/arqui... ^,3030 Critchley JA, Capewell S. Mortality risk reduction associated with smoking cessation in patients with coronary heart disease: a systematic review. JAMA 2003; 290(1):86-97.. In overweight people, it also is common to identify metabolic alterations that result in DM¹¹11 Oliveira JEP, Vencio S. Diretrizes da Sociedade Brasileira de Diabetes, 2013-2014 [Internet]. Sociedade Brasileira de Diabetes; 2014. [acessado 2021 jul 16]. Disponível em: http://www.sgc.goias.gov.br/upload/arquivos/2014-05/diretrizessbd-2014.pdf
http://www.sgc.goias.gov.br/upload/arqui... .

The protective effect of excessive alcohol consumption found in the adjusted analyses, estimated for half of the population with DM, also suggests possible changes in lifestyle, such as a reduction in alcohol consumption. The present study highlights that alcohol consumption is not recommended for people with diabetes; therefore, guideline concerning DM lead health professionals to discourage the use of alcohol to facilitate the glycemic control of those patients³²32 Brasil. Ministério da Saúde (MS). Estratégias para o cuidado da pessoa com doença crônica: diabetes mellitus. Brasília: MS; 2013.as well as to achieve more favorable¹ outcomes, thus constituting a reverse causality effect. Moreover, that variable refers to abusive consumption or binging, which tends to be more common among young individuals³³33 Sanchez ZM. Binge drinking among young Brazilians and the promotion of alcoholic beverages: a public health concern. Epidemiol Serv Saude 2017; 26(1):195-198., and the prevalence of DM in that age group is lower.

The prevalence of protective foods investigated here was higher among individuals with DM, but the association between the consumption of healthy foods and diabetes disappeared when adjusted by age, education, and sex, which was also identified in a previous study¹⁸18 World Health Organization (WHO). Obesity: preventing and managing the global epidemic [Internet]. Geneva: World Health Organization; 2000 [cited 2021 may 11]. Available from: https://apps.who.int/iris/handle/10665/42330. The self-reported consumption of salt was lower among patients with DM, but it showed no significance after the adjustment for the selected variables. It should be emphasized that the consumption of 400 grams of fruit, vegetables, and salad; the encouragement of such foods as minimally processed grains; beans; and the reduction of fat consumption and salt are part of the guidelines recommended by health professionals to individuals with DM, and such changes in habits may explain the findings of this study, of a cross-sectional cohort¹1 Sociedade Brasileira de Diabetes. Diretrizes da Sociedade Brasileira de Diabetes 2019-2020 [Internet]. 2019. [cited 2021 aug 16]. Available from: http://www.saude.ba.gov.br/wp-content/uploads/2020/02/Diretrizes-Sociedade-Brasileira-de-Diabetes-2019-2020.pdf
http://www.saude.ba.gov.br/wp-content/up... ^,3232 Brasil. Ministério da Saúde (MS). Estratégias para o cuidado da pessoa com doença crônica: diabetes mellitus. Brasília: MS; 2013..

The regular practice of physical activities is important for the treatment and reduction of diabetes, since it may contribute to the reduction of the use of hypoglicemics³²32 Brasil. Ministério da Saúde (MS). Estratégias para o cuidado da pessoa com doença crônica: diabetes mellitus. Brasília: MS; 2013., and it improves the metabolic control in relation to the absorption of glucose by body tissues³⁴34 Streb AR, Leonel LDS, Silva CSD, Silva RPD, Duca GFD. Associação entre a prática de atividade física em diferentes domínios e o uso de insulina em adultos e idosos com diabetes no Brasil. Cien Saude Colet 2020; 25(11):4615-4622.. Sedentary lifestyles are associated with a higher insulin resistance¹1 Sociedade Brasileira de Diabetes. Diretrizes da Sociedade Brasileira de Diabetes 2019-2020 [Internet]. 2019. [cited 2021 aug 16]. Available from: http://www.saude.ba.gov.br/wp-content/uploads/2020/02/Diretrizes-Sociedade-Brasileira-de-Diabetes-2019-2020.pdf
http://www.saude.ba.gov.br/wp-content/up... ^,1111 Oliveira JEP, Vencio S. Diretrizes da Sociedade Brasileira de Diabetes, 2013-2014 [Internet]. Sociedade Brasileira de Diabetes; 2014. [acessado 2021 jul 16]. Disponível em: http://www.sgc.goias.gov.br/upload/arquivos/2014-05/diretrizessbd-2014.pdf
http://www.sgc.goias.gov.br/upload/arqui... ^,3535 Mayer-Davis EJ, D'Agostino R Jr, Karter AJ, Haffner SM, Rewers MJ, Saad M, Bergman RN. Intensity and amount of physical activity in relation to insulin sensitivity: the Insulin Resistance Atherosclerosis Study. JAMA 1998; 279(9):669-674.. The advice for the regular practice of physical activities is part of the recommendations given by health professionals to patients; however, the association found in this study was that patients with DM are likely to practice less physical activities²⁹29 Malta DC, Moura L, Bernal RTI. Differentials in risk factors for chronic non-communicable diseases from the race/color standpoint. Cien Saude Colet 2015; 20(3):713-725.^,3232 Brasil. Ministério da Saúde (MS). Estratégias para o cuidado da pessoa com doença crônica: diabetes mellitus. Brasília: MS; 2013.. Since the majority of the DM patients are elderly individuals, the recommended physical activity level is not always reached by this population²⁹29 Malta DC, Moura L, Bernal RTI. Differentials in risk factors for chronic non-communicable diseases from the race/color standpoint. Cien Saude Colet 2015; 20(3):713-725., and it continues to be important medical advice for patients at the time of the diagnosis of DM.

Concerning health conditions, the study indicated a strong association between having DM and the evaluation of one’s own health being regular or bad/very bad, with a dose response gradient. The findings are in conformity with the literature¹⁶16 Malta DC, Bernal RTI, Iser BPM, Szwarcwald CL, Duncan BB, Schmidt MI. Fatores associados ao diabetes autorreferido segundo a Pesquisa Nacional de Saúde, 2013. Rev Saude Publica 2017; 51(Supl. 1):12s.^,3838 Molarius A, Berglund K, Eriksson C, Lambe M, Nordström E, Eriksson HG, Feldman I. Socioeconomic conditions, lifestyle factors, and self-rated health among men and women in Sweden. Eur J Public Health 2006; 17(2):125-133.^,3737 Theme Filha MM, Souza Junior PR, Damacena GN, Szwarcwald CL. Prevalence of chronic non-communicable diseases and association with self-rated health: National Health Survey, 2013. Rev Bras Epidemiol 2015; 18 (Suppl. 2):83-96.. This indicator is a predictor of severe outcomes, including mortality⁶6 Iser BPM, Stopa SRS, Chueri PS, Szwarcwald CL, Malta DC, Monteiro HOC, Ducan BB, Schmidt MA. Self-reported diabetes prevalence in Brazil: results from National Health Survey 2013. Epidemiol Serv Saude 2015; 24(2):305-314.^,3838 Molarius A, Berglund K, Eriksson C, Lambe M, Nordström E, Eriksson HG, Feldman I. Socioeconomic conditions, lifestyle factors, and self-rated health among men and women in Sweden. Eur J Public Health 2006; 17(2):125-133., and constitutes a qualitative evaluation of the state of health. The perception, in general, relates to the worsening of health, besides objective questions, such as the more frequent use of health services, changes in lifestyles, limitations in daily physical activity, and worse quality of life³⁶36 Barros MBA, Zanchetta LM, Moura EC, Malta DC. Self-rated health and associated factors, Brazil, 2006. Rev Saude Publica 2009; 43 (Suppl. 2):27-37. https://doi.org/10.1590/S0034-89102009000900005^,3838 Molarius A, Berglund K, Eriksson C, Lambe M, Nordström E, Eriksson HG, Feldman I. Socioeconomic conditions, lifestyle factors, and self-rated health among men and women in Sweden. Eur J Public Health 2006; 17(2):125-133., indicating the burden of DM on the life of those individuals.

The present study also illustrated an association between being overweight or obese and having DM, which is well described in the literature¹1 Sociedade Brasileira de Diabetes. Diretrizes da Sociedade Brasileira de Diabetes 2019-2020 [Internet]. 2019. [cited 2021 aug 16]. Available from: http://www.saude.ba.gov.br/wp-content/uploads/2020/02/Diretrizes-Sociedade-Brasileira-de-Diabetes-2019-2020.pdf
http://www.saude.ba.gov.br/wp-content/up... ^,1111 Oliveira JEP, Vencio S. Diretrizes da Sociedade Brasileira de Diabetes, 2013-2014 [Internet]. Sociedade Brasileira de Diabetes; 2014. [acessado 2021 jul 16]. Disponível em: http://www.sgc.goias.gov.br/upload/arquivos/2014-05/diretrizessbd-2014.pdf
http://www.sgc.goias.gov.br/upload/arqui... ^,2727 Moraes SA, Freitas ICM, Gimeno SGA, Mondini L. Prevalência de diabetes mellitus e identificação de fatores associados em adultos residentes em área urbana de Ribeirão Preto, São Paulo, Brasil, 2006: Projeto OBEDIARP. Cad Saude Publica 2010; 26(5):929-941.

28 Stopa SR, Malta DC, Monteiro CN, Szwarcwald CL, Goldbaum M, Cesar CLG. Acesso e uso de serviços de saúde pela população brasileira, Pesquisa Nacional de Saúde 2013. Rev Saude Publica 2017; 51(Supl. 1):3s.

29 Malta DC, Moura L, Bernal RTI. Differentials in risk factors for chronic non-communicable diseases from the race/color standpoint. Cien Saude Colet 2015; 20(3):713-725.

30 Critchley JA, Capewell S. Mortality risk reduction associated with smoking cessation in patients with coronary heart disease: a systematic review. JAMA 2003; 290(1):86-97.

31 Yeh HC, Duncan BB, Schmidt MI, Wang NY, Brancati FL. Smoking, smoking cessation, and risk for type 2 diabetes mellitus: a cohort study. Ann Intern Med 2010; 152(1):10-17.

32 Brasil. Ministério da Saúde (MS). Estratégias para o cuidado da pessoa com doença crônica: diabetes mellitus. Brasília: MS; 2013.

33 Sanchez ZM. Binge drinking among young Brazilians and the promotion of alcoholic beverages: a public health concern. Epidemiol Serv Saude 2017; 26(1):195-198.

34 Streb AR, Leonel LDS, Silva CSD, Silva RPD, Duca GFD. Associação entre a prática de atividade física em diferentes domínios e o uso de insulina em adultos e idosos com diabetes no Brasil. Cien Saude Colet 2020; 25(11):4615-4622.

35 Mayer-Davis EJ, D'Agostino R Jr, Karter AJ, Haffner SM, Rewers MJ, Saad M, Bergman RN. Intensity and amount of physical activity in relation to insulin sensitivity: the Insulin Resistance Atherosclerosis Study. JAMA 1998; 279(9):669-674.

36 Barros MBA, Zanchetta LM, Moura EC, Malta DC. Self-rated health and associated factors, Brazil, 2006. Rev Saude Publica 2009; 43 (Suppl. 2):27-37. https://doi.org/10.1590/S0034-89102009000900005

37 Theme Filha MM, Souza Junior PR, Damacena GN, Szwarcwald CL. Prevalence of chronic non-communicable diseases and association with self-rated health: National Health Survey, 2013. Rev Bras Epidemiol 2015; 18 (Suppl. 2):83-96.

38 Molarius A, Berglund K, Eriksson C, Lambe M, Nordström E, Eriksson HG, Feldman I. Socioeconomic conditions, lifestyle factors, and self-rated health among men and women in Sweden. Eur J Public Health 2006; 17(2):125-133.

39 Moraes SA, Freitas ICM, Gimeno SGA, Mondini L. Prevalência de diabetes mellitus e identificação de fatores associados em adultos residentes em área urbana de Ribeirão Preto, São Paulo, Brasil, 2006: Projeto OBEDIARP. Cad Saude Publica 2010; 26(5):929-941.

40 Cerf ME. Beta cell dysfunction and insulin resistance. Front Endocrinol (Lausanne). 2013; 4:37.^-4141 Passos VMA, Barreto SM, Diniz LM, Lima-Costa MF. Type 2 diabetes: prevalence and associated factors in a Brazilian community - the Bambui health and aging study. Sao Paulo Med J 2005; 123(2):66-71.. The increase in obesity in the Brazilian population may worsen this scenario. Obesity results in the infiltration of fat in the liver, changing the metabolism and resulting in insulin resistance. The excess of fats and glucose in the circulation increases the secretion of insulin by the pancreas, leading to the exhaustion of the beta cells (β)¹¹11 Oliveira JEP, Vencio S. Diretrizes da Sociedade Brasileira de Diabetes, 2013-2014 [Internet]. Sociedade Brasileira de Diabetes; 2014. [acessado 2021 jul 16]. Disponível em: http://www.sgc.goias.gov.br/upload/arquivos/2014-05/diretrizessbd-2014.pdf
http://www.sgc.goias.gov.br/upload/arqui... ^,4040 Cerf ME. Beta cell dysfunction and insulin resistance. Front Endocrinol (Lausanne). 2013; 4:37.. Other health associated conditions included hypertension, heart disease, and high cholesterol, also related to the nutritional state of the individual, indicating the syndemic of factors common to the occurrence of chronic diseases⁴²42 Mendenhall E, Kohrt BA, Norris SA, Ndetei D, Prabhakaran D. Non-communicable disease syndemics: poverty, depression, and diabetes among low-income populations. Lancet 2017; 389(10072):951-963.. The literature indicates that low levels of high density lipoprotein cholesterol (HDL-C) and high levels of triglycerides may be associated with DM⁴¹41 Passos VMA, Barreto SM, Diniz LM, Lima-Costa MF. Type 2 diabetes: prevalence and associated factors in a Brazilian community - the Bambui health and aging study. Sao Paulo Med J 2005; 123(2):66-71.^,4343 Schofield JD, Liu Y, Rao-Balakrishna P, Malik RA, Soran H. Dyslipidemia. Diabetes Ther 2016; 7(2):203-219., as well as hypertension and cardiovascular diseases, due to micro and macrovascular lesions¹¹11 Oliveira JEP, Vencio S. Diretrizes da Sociedade Brasileira de Diabetes, 2013-2014 [Internet]. Sociedade Brasileira de Diabetes; 2014. [acessado 2021 jul 16]. Disponível em: http://www.sgc.goias.gov.br/upload/arquivos/2014-05/diretrizessbd-2014.pdf
http://www.sgc.goias.gov.br/upload/arqui... ^,4040 Cerf ME. Beta cell dysfunction and insulin resistance. Front Endocrinol (Lausanne). 2013; 4:37.. Furthermore, these conditions are common in diabetic people due to metabolic alterations¹1 Sociedade Brasileira de Diabetes. Diretrizes da Sociedade Brasileira de Diabetes 2019-2020 [Internet]. 2019. [cited 2021 aug 16]. Available from: http://www.saude.ba.gov.br/wp-content/uploads/2020/02/Diretrizes-Sociedade-Brasileira-de-Diabetes-2019-2020.pdf
http://www.saude.ba.gov.br/wp-content/up... , and such comorbidities are responsible for a high morbimortality among those patients⁴⁴44 Klafke A, Duncan BB, Rosa RS, Moura L, Malta DC, Schmidt MI. Mortalidade por complicações agudas do diabetes melito no Brasil, 2006-2010. Epidemiol Serv Saude 2014; 23(3):455-462.^,4545 Rosa R, Nita ME, Rached R, Donato B, Rahal E. Estimated hospitalizations attributable to Diabetes Mellitus within the public healthcare system in Brazil from 2008 to 2010: study DIAPS 79. Rev Assoc Med Bras 2014; 60(3):222-230., since they increase cardiovascular risk¹1 Sociedade Brasileira de Diabetes. Diretrizes da Sociedade Brasileira de Diabetes 2019-2020 [Internet]. 2019. [cited 2021 aug 16]. Available from: http://www.saude.ba.gov.br/wp-content/uploads/2020/02/Diretrizes-Sociedade-Brasileira-de-Diabetes-2019-2020.pdf
http://www.saude.ba.gov.br/wp-content/up... .

Among the limitations of this study are those which are inherent to cross-sectional study designs, determined by simultaneous measurements of risk factors or protection factors and the outcomes, which limit inferences about the directionality of some of the associations in the causality model. It is important to note the bias of reverse causality, or the changes in the lifestyle determined by the disease and by the advice from health professionals. The use of self-reported morbidity data depends on the access to health services for the diagnosis; therefore, individuals who use the service more often have a greater opportunity of receiving a diagnosis of diabetes.

Regardless of the limitations of cross-sectional studies, the results of the PNS presented in this study allowed us to establish a set of factors associated with diabetes, thus contributing to subsidize public policies for health promotion and for the evidence-based prevention of diseases. After the adjustments by age, education, and sex, it was found that diabetes was associated with older age, lower education, income, poor health conditions, and lifestyles, indicating a pattern of risk factors also common to other NCDs in the Brazilian adult population. The close association between diabetes and self-assessment of poor health shows the implications of the disease in the lives of Brazilian adults and the elderly. It is also important to mention the increase in obesity and life expectancy, which may worsen such a situation.

The information in the PNS is representative of the Brazilian population and is therefore useful to support the reformulation of public surveillance policies and of health care by SUS, aligned with the Plan for Strategic Actions to Curb NCDs in Brazil, with the Global Plan for curbing NCDs from 2013⁴⁶46 World Health Organization (WHO). WHO Global NCD Action Plan 2013-2020. Genebra: WHO; 2013., and with the objectives of sustainable development⁴⁷47 United Nations (UN). Transforming our world: the 2030 Agenda for Sustainable Development [Internet]. 2016. [cited 2021 Aug 11]. Available from: https://sdgs.un.org/2030agenda
https://sdgs.un.org/2030agenda... , thereby establishing national and global commitments.

Furthermore, the COVID-19 pandemic worsened NCDs, since it determined worse lifestyles and less access to health services⁴⁸48 Malta DC, Szwarcwald CL, Barros MBA, Gomes CS, Machado IE, Souza Júnior PRB, Romero DE, Lima MG, Damacena GN, Pina MF, Freitas MIF, Werneck AO, Silva DRPD, Azevedo LO, Gracie R. A pandemia da COVID-19 e as mudanças no estilo de vida dos brasileiros adultos: um estudo transversal, 2020. Epidemiol Serv Saude 2020; 29(4):e2020407.^,4949 Malta DC, Gomes CS, Barros MBA, Lima MG, Almeida WDS, Sá ACMGN, Prates EJS, Machado IE, Silva DRPD, Werneck AO, Damacena GN, Souza Júnior PRB, Azevedo LO, Montilla DER, Szwarcwald CL. Doenças crônicas não transmissíveis e mudanças nos estilos de vida durante a pandemia de COVID-19 no Brasil. Rev Bras Epidemiol 2021; 24:e210012., which may well make the control and prevention of DM in Brazil even more difficult. Hence, we emphasize the importance of monitoring the disease, as well as health promotion programs and interventions, in favor of more healthy nutrition, more physical activity, restrictions to tobacco and alcohol consumption, obesity controls, and long-term care in terms of primary health care.

Acknowledgements

To the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) for the productivity grant awarded to DC Malta (process number: 310177/20200). To the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) for the doctoral grant awarded to the author ACMGN Sá (process number: 88882.380997/2019-01). For the funding granted by the National Health Fund, Health Surveillance Secretary, TED:66/2018.

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