This is the largest study evaluating the prevalence of high blood glucose levels and regarding risk for developing diabetes ever conducted in pharmacies in all regions of Brazil. Performing NCD screening is important because it can identify asymptomatic people at high risk or with initial signs and symptoms of a disease, allowing for timely diagnosis and treatment and this is very important for a disease such as diabetes. The prevalence of people with high CBG levels, demonstrated in the present study, indicated that the country has approximately 38 million people that should be monitored by the health system either private or public.
According to the WHO, a substantial fraction of the disease burden and mortality due to NCD are related to a small set of risk factors, among which stand out smoking, inadequate food consumption, physical inactivity, and excessive consumption of alcoholic beverages . Early detection of people at risk of developing T2DM is very important, since changes in lifestyle, including physical activity and proper diet, can reduce the incidence of the disease by approximately 58% [16, 20, 35]
It was found that the prevalence of high CBG levels was higher in the Midwest, North, and Northeast regions. These findings can be explained by the heterogeneous profile of the Brazilian population, related to lifestyle and prevalence of obesity which has been increasing. Indeed, acccording to data from Vigitel 2018 , the prevalence of obesity (BMI > 30 kg/m2) in adults is 19.8%, with the highest frequencies observed in capitals of the Midwest, North, and Northeast regions, with emphasis on the capital cities like Cuiabá (23.0% CI 95% 20.5–25.4), Manaus (23.0% CI 95% 19.7–26.3), and Recife (21.9% CI 95% 19.3–24.4). The same pattern was observed regarding the consumption of fruits and vegetables, with the lowest percentages observed in the North and Northeast regions . The Vigitel survey also pointed out that consumption of fruits and vegetables is more frequent among women and, despite the increase in the consumption of these foods observed in the last ten years, only 23.1% of Brazilians consume the five daily portions at least five times a week as recommended by the WHO . In Brazil, overweight (BMI > 25 kg/m2) and obesity rates are spreading in all age groups, both sexes, and all income levels, with the obesity rates being more frequent in the population with lower family income .
Similar to the results reported by Passos et al. (2005), it was verified a positive relationship between physical inactivity and high CBG . Sedentary lifestyle has been associated with insulin resistance in individuals without a diagnosis of diabetes, regardless of obesity [39, 40]. Reporting of previous arterial hypertension was also associated with high CBG. It is known that hypertension has a prevalence up to three times higher in people with DM when compared to those who do not have the disease, being the major determinant of atherosclerotic cardiovascular diseases (ASCVD) in this population [41, 42].
The percentage of people at high and very high risk of developing T2DM in Brazil was similar to the screening performed in pharmacies in Spain (23.5% had a high risk of diabetes -FINDRISC > 14 points)  and smaller than the risk reported by the screening performed in Thailand, in seven pharmacies, which showed a prevalence of 48% of high risk for DM . The prevalence of high CBG in Brazil was higher than the prevalence found in other countries such as Spain, Switzerland, and Thailand [43–45], indicating the need for multidisciplinary monitoring of these people.
T2DM is characterized by a long asymptomatic period before the diagnosis is made . The early diagnosis of T2DM contributes to the reduction of ASCVD, prevention of microvascular complications (retinopathy, neuropathy, kidney disease), and premature mortality [16, 40, 46, 47]. People with T2DM have a two to four times greater risk of developing coronary heart disease, when compared to the general population, and approximately 8% of people with pre-diabetes develop retinopathy (Alberti et al. 2007). Moreover, more recent data have shown high percentages of peripheral neuropathy among people with obesity and pre-DM 29% versus 11% with normal glucose, and ranges from 11 to 34% among individuals with pre-DM . Thus, early interventions to prevent or delay progression to T2DM represent an important benefit not only for, increasing life expectancy and quality of life, but also reducing costs related to the management of the disease and its complications .
Success in the treatment of diabetes depends on the concomitant implementation of three types of interventions: educational, self-monitoring, and pharmacological strategies. Whenever possible, it is recommended that care for people with diabetes should include a health care professional (HCP) interdisciplinary team composed of professionals with the proper qualification and practical experience in health education activities . Pharmacists working in community pharmacies can contribute not only with HCP screening and education, but also with the monitoring of patients with DM, in collaboration with other HCP thus helping to improve the treatment and disease control.
A systematic review and meta-analysis assessing the impact of pharmaceutical care for people with diabetes in outpatient services, revealed a 1.1% reduction in HbA1c compared to standard care (95% CI 0.88–1.27 ). In Brazil, a 12-months study enrolling patients with DM, followed in a pharmacy, showed a reduction of 2.2% in HbA1c compared to 0.3% in the control group . These studies suggest that the health care intervention by the pharmacist in patients with DM can improve the HbA1c results acting as an “additional” effect to the standard care provided to the patient. Other parameters such as blood pressure, LDL cholesterol, triglycerides, BMI, and coronary risk were also sensitive to pharmaceutical intervention in this group of patients, as reported by Pousinho et al. .
Barcelo et al. found that, most of the direct costs of treating DM in Latin America are related to the treatment of complications. The cost of a patient without chronic complications with HbA1c > 10% is 2.4 times higher than that of a patient better controlled with HbA1c < 8%. If the patient develops chronic complications, the resultant cost is 34 times higher . Therefore, population-based DM screening actions can generate cost-effective results . The campaign to track suspected cases of DM in Brazil, in 2018, reached a population larger than the number initially estimated, reinforcing the role of pharmacies in health promotion and disease prevention activities. As in other countries [44, 45], pharmacies in Brazil are health establishments that provide pharmaceutical services, individual and collective health guidance, handling and/or dispensing medications, and evaluation of CBG, blood pressure and weight measurements, among other procedures [26, 27]. Thus, pharmacies are favorable environments for carrying out clinical activities, including screening, education, and monitoring of people with NCD, particularly diabetes .