The BrazDiab1SG is a survey that analyzes the demographic, clinical and socioeconomic data of T1D patients receiving treatment in secondary and tertiary care public clinics in Brazil.
In the present study, great variability was found in the proportion of patients screened for diabetes-related complications and in the proportion of patients reaching their targets depending on the variables evaluated and on the geographic region of the country. The southeast and south regions were quite similar regarding patient’s demographic and economic characteristics but with an important difference from the patients from the north/northeast and mid-west. Overall, more patients from the north/northeast attended secondary care level centers, tended to be younger, tended to be non-Caucasian and tended to be from a lower economic status.
For most patients, blood pressure levels were within the goals. However, glycemic control was unsatisfactory in the majority of the study patients. Being overweight was an important issue in all regions of the country and was observed in one-third of the study patients. Additionally, approximately half of the patients were not screened for diabetic complications in the previous year. It is important to mention that all of the patients were treated by an endocrinologist at secondary and tertiary care clinics.
The treatment of diabetes in Brazil is guided by the Brazilian Diabetes Society , whose recommendations are essentially the same as those of the ADA. Considering that diabetes treatment in public clinics is financed by the National Brazilian Health Care System, the present data showed that factors other than medical recommendations likely interfere with diabetes care in Brazil, especially social and economic factors. The latter fact may be associated with the low or very low economic status that was found in up to 87% of the studied patients, mainly in the north/northeast region of the country. Notably, economic status in Brazil also takes into account educational level. In the last Brazilian population census , the north/northeast region presented a higher number of illiterates (12.2%) than the national average (9.7%) and the proportion observed in the southeast (4.45%), south (4.26%), and mid-west (6%). Considering the existing complexity of T1D management, the above-mentioned facts may have influenced the lower use of CSII, SBGM and intermediate-acting/long-acting plus short-acting insulin by the north/northeast region. Although patients from the north/northeast region had a lower duration of diabetes, it is important to emphasize that no difference was observed concerning the number of visits to a specialist in the prior year among all of the geographic regions of the country.
The present study found great heterogeneity in the type of human intermediate-acting/long-acting plus short-acting insulin used by the patients across the Brazilian geographic regions. Although the most frequent type of association in all regions was human intermediate-acting insulin NPH with regular human insulin, the combination of insulin glargine with insulin lispro or glulisine was more frequently used in the mid-west region. No clear explanation exists for this trend, but it may be explained by the local health policy responsible for the acquaintance of insulin. Although diabetes treatment in public clinics is financed by the National Brazilian Health Care System, it is important to emphasize that each city’s health bureau acts independently from the federal government and has its own rules concerning the choice of what type of insulin they are going to purchase and furnish to their diabetic population.
Approximately 13.8% of the HbA1c determinations, mainly in the north/northeast and mid-west regions, were excluded due to the following reasons: the methods used were not certified by the NGSP; existence of missing data; or the HbA1c level was determined more than one year before the study assessment. Moreover, among those patients who had undergone HbA1c measurements in the prior year to the study, the average number of measurements was also different across the geographic regions, with a lower number performed in the north/northeast and mid-west regions. In general, patients from the southeast and south regions performed a similar number of HbA1c determination to that proposed by ADA guidelines  and the Brazilian Diabetes Society recommendations  but varied widely from one to ten per year. This range indicates that there is no agreement in Brazil regarding the number of HbA1c measurements routinely performed to monitor the treatment of a patient with T1D. Other factors related to the physician’s interpretation of the test might explain these discrepancies.
Although most patients had complex therapeutic regimens and performed SBGM, more than 40% of the patients had HbA1c levels greater than 9%, thereby indicating poor glycemic control. Although the north/northeast and south regions had the highest average HbA1c levels, the lowest proportion of patients reaching the goal of HbA1c was observed in the south region. However, it is important to emphasize that in the multivariate analysis (after correcting for age, economic status, gender and daily frequency of SBGM) neither the geographic region of the country nor the type of insulin regimen that was used reached statistical significance. The latter fact must be analyzed in the context of the high costs of CSII and long-acting insulin analogues (glargine and detemir). Although the present study was not designed to evaluate the cost-effectiveness of both types of treatment, the data could add new insights for reforming the guidelines of the National Brazilian Health Care System concerning the treatment of T1D in Brazil. Thus far, the majority of the studies that have addressed this issue have found that both types of treatment are mainly associated with an improvement in the occurrence of severe hypoglycemia but not with improved glycemic control, thereby showing that a gap exists between the large amounts of money spent with the treatment of T1D and the final outcomes in terms of glycemic and CV risk factors control [20–24]. However, the overall difficulty in achieving glycemic control in T1D patients through routine care is described in many observational studies worldwide [17–19, 25–28].
Currently, the therapeutic and clinical management of weight, cholesterol and blood pressure is of great importance for delaying or preventing diabetes-related microvascular and macrovascular complications. Although most of the studied patients achieved the sBP, dBP and HDL cholesterol goals, 30 to 50% did not reach the goals for triglycerides, LDL cholesterol and non-HDL cholesterol levels, which was similar to the data found in other observational studies [7, 18, 28–30]. Although there is a slight prevalence of patients that have reached BMI levels resembling Brazilian overweight/obesity statistics , the present results suggested an additional major health issue in T1D patients in all geographic regions is overweight or obese patients, which was similar to results found in other populations with T1D [7, 18, 32, 33] and in patients with T2D in Brazil .
Although the guidelines recommend aggressive dyslipidemia and hypertension treatments in T1D patients, despite the presence of high BP and LDL cholesterol, up to 50% of the studied patients were not receiving treatment for both clinical conditions during this study. Similar results have also been described in Sweden . Hypertension was observed in 19.2% of the patients with a higher proportion in patients from the mid-west and north/northeast regions than patients from the southeast and south regions. Until recently, no data were available concerning hypertension prevalence in T1D Brazilian patients. Overall, almost half of the studied patients had some type of dyslipidemia, but only 7.9% of these patients were using statins for dyslipidemia. Of these patients, fewer than 50% were at LDL cholesterol goals. More patients from the southeast reached the target for LDL cholesterol than patients from the other regions, which may have been due to the more regular use of statins than patients from the other geographic regions. To the best of our knowledge, this is the first study to address the abovementioned comorbidities in T1D in a multicenter study in Brazil.
The Pittsburgh Epidemiology of Diabetes Complications Study used different targets for blood pressure and LDL cholesterol, and it demonstrated small improvements in hypertension and dyslipidemia control primarily in younger groups of T1D patients over a 10-year follow-up period . With regard to T1D patients who were above their goal, one study at academic medical centers observed a low rate of medication management . Considering overweight, obesity, hypertension and dyslipidemia as CV risk factors, it can be concluded that the young patients in the present study represent a high-risk group for microvascular and macrovascular complications of diabetes, as described in other studies [30, 32, 33]. Although a high number of current smokers were noted in the south region in the present study, there were fewer T1D patients who were current smokers than previously reported in Europe  and USA .
Despite that almost one-third of the patients did not fulfill the criteria for screening for diabetic complications, up to 60% of the patients conforming to the inclusion criteria had not been screened for diabetic chronic complications in the previous year. In general, the screening for diabetic chronic complications was documented more in the south region, followed by the southeast region. Fundoscopy and urine albumin testing were not documented in up 60% of the patients. Notably, urine albumin evaluation is now regularly performed in 75% of the public hospitals included in the present study. Moreover, the simplest screening for diabetes-related complications, which is feet examination, was not routinely performed in up to 45% of the patients.
The principal strength of the large sample groups in the present study is that the included cases are representative of the distribution of T1D in the diverse, young Brazilian population. Moreover, the epidemiological information obtained from this study is important for guiding governmental health policy decisions aimed at improving diabetes care in Brazil, according to each geographic region of the country.
Several limitations of the present study must be addressed. One limitation is the sample characteristics. Similar to other studies, a clinical definition of T1D assigned by physicians that was applicable to all patients was used. However, as autoantibodies and C-peptide levels were not measured, some patients with other types of diabetes may have been included. Nevertheless, it is important to emphasize that 96.5% of the patients were diagnosed before 30 years of age, which reinforces the high probability that they most likely had T1D. All patients were followed in a public center by a specialist and lived in large cities. Patients who rely on private clinics, primary care facilities and live in rural areas may not have been included. However, this group of T1D patients is considered to be the minority of those receiving treatment in Brazil. Another limitation is the lack of standardization for evaluating HbA1c levels. Although two different methods to determine HbA1c levels were used across the country, different upper limits of normality for the same method may be present. This variation may have also influenced the results of the present study. However, this variation in methods is still an unsolved problem in Brazil. Moreover, the consideration of self-reported hypertension as a criterion of the presence of the comorbidity may have led to misdiagnosis and lower reliability in determining the real prevalence of hypertension.