Profile of Hiperdia patients in the municipality of Barra Bonita, Sao Paulo state

Introduction: The “Hiperdia System” sets goals and guidelines to expand prevention, diagnosis, treatment and control of Diabetes Mellitus and Hypertension. Knowing the epidemiological characteristics of the population is important to strengthen public health programs. Objective: The objective of the study was to describe the sociodemographic pro ile, risk factors and complications of hypertensive, diabetic and hypertensive diabetic people registered in the HiperDia system of the Ministry of Health of the Basic Health Units (Unidades Básicas de Saúde UBS) in Barra Bonita, São Paulo State. Methods: This is a descriptive cross-sectional study, which used 113 medical records of diabetic and hypertensive patients as a data source for information about gender, age, race, education, marital status, body mass index (BMI), family history, smoking, sedentarism, acute myocardial infarction, stroke, kidney disease, amputation and diabetic foot. Descriptive statistics were used. Results: As a result, the epidemiological pro ile of patients registered in the HiperDia system was characterized by: a mean age of 57.3 years; 61.9% women, 82.1% Caucasians, 66.4% with education level up to incomplete primary education, 48.5% lived with partners and children, 19.5% were smokers, 51.4% were sedentary, 44.3% were overweight and obese and 69% had a diagnosis of hypertension and diabetes. Conclusion: The results were relevant allowing professionals and health managers to institute preventive programs to intervene in the risk factors involved in the genesis and complications of hypertension and diabetes.


Introduction
The chronic non-communicable diseases (NCDs) represent one of the biggest changes in world public health in the last decades (1), becoming the main priority in the health area in Brazil. In 2007, about 72% of the deaths were attributed to these diseases (2). Among the NCDs, the systemic arterial hypertension (SAH) and the diabetes mellitus (DM) are considered the main risk factors for the development of heart diseases, such as the acute myocardial infarction (AMI) and the stroke (EVA), besides the chronic kidney disease (1,3).
According to the World Health Organization (WHO), in 2010, the estimate in adults of the prevalence of DM was of 6.4%, corresponding to 285 million people. Data of the TI Department of the Uni ied Health System (4), referring to the year 2012, point to a vertiginous increase in adults (above the age of 35 years), with a prevalence of 11.7% of diabetic people in Brazil. In accordance with data of the International Diabetes Federation (5), Brazil is in the fourth position among the countries with a bigger prevalence of DM, presenting 13.4 million people with the disease.
The SAH is present in 69% of the patients with AMI, 77% of the stroke (EVA), 74% in chronic heart failure (CHF) and 60% with peripheral artery disease (1). Studies on the SAH in Brazilian cities in last the 20 years pointed to a prevalence above 30% of the population, among these cities we ind São Jose do Rio Preto (SP) and Nobres (MT). Considering MAP values ≥ 140/90 mmHg, studies found prevalence above 50% in the age group from 60 to 69 years and 75% above 70 years old (6,7).
Intending to minimize this situation, a Reorganization Plan of SAH and DM Care, called HiperDia, was created in Brazil, in 2002. Its function is to monitor patients taken care of and registered in the Family Health Strategy (FHS), part of the Uni ied Health System (SUS), and to raise information for the distribution of medicine among these patients (8). This system also sets goals and guidelines to expand actions of prevention, diagnosis, treatment and control of several risk factors of these pathologies (9).
Personal and familiar history, smoking, obesity and sedentarism are also considered risk factors of SAH and DM (10,11). On the other hand, the modiication in the life style, such as an appropriate diet, weight control, restriction to smoking, alcohol consumption and the regular practice of physical exercises contribute to the control of these diseases` risk factors (12).
Therefore, the present study aimed to describe the sociodemographic pro ile, the risk factors and the complications of the hypertensive, diabetic and hypertensive diabetic registered in the HiperDia system of the Ministry of Health of the Basic Health Units (UBS) of the municipality of Barra Bonita, São Paulo.

Methods
It is a descriptive cross-sectional study, using data of the medical records of the diabetic and hypertensive patients, users of the Hiperdia in the UBS of the municipality of Barra Bonita, São Paulo State (Brazil). The Research Ethics Committee of the Universidade do Sagrado Coração approved this study (n.870.011 on 10/29/14).
The subjects were diabetic and hypertensive users, registered in the HiperDia system of the ive UBS of the municipality (Vila Habitacional, Health Center, Cohab, Dream Ours and Vila Correa). We analyzed medical records of the HiperDia regarding the period from January to June 2013. The medical records that were incomplete or had wrong data were excluded.
The data collection instrument was a pre-coded questionnaire, elaborated from the registration form of the HiperDia system, following the strati ications and classi ications of the form. The independent variables included in the analysis were: gender (male, female); age (20 to 35, 36 to 59 and 60 years or more); skin color, classi ied in accordance with the patient`s perception (Caucasian, black, yellow, brown); education (illiterate, primary school incomplete, primary school complete, secondary school incomplete, secondary school complete and higher education complete); marital status (with a partner, without a partner, lives alone); body mass index (BMI), according to the classi ication of the World Health Organization (WHO, 1995) in normal weight (BMI ≥ 18.5kg/m2 and < 25kg/m2), overweight (BMI ≥ 25kg/m2 and < 30kg/m2) and obesity (IMC ≥ 30 kg/m2); measure of the abdominal circumference (102 cm and 88 cm considered as superior limits of AC in the male and female, respectively in accordance with the Brazilian Society of Diabetes, 2007); presence of hypertension, diabetes, family history, smoking (the information in the registration form of the HiperDia comprises data on smoking only at the moment of the registration, it doesn´t consider previous smoking), sedentarism, acute myocardium infarction, another heart disease, EVA, kidney disease, diabetic foot and amputation for diabetes, categorized as yes and not.
With the totality of the data collected, we carried out the codi ication of the instruments and the construction of the database on the Microsoft Of ice Excel, version 2013. After that, we carried out the strati ication and categorization of the variables collected. For the analysis of the data, a descriptive statistics was used, and the values were expressed in absolute frequency (n) and relative frequency (%).

Results
We obtained information of the database of the HiperDia System, centralized in the City Health Department of the municipality of Barra Bonita. In this database, there were 3.456 patients registered; however, they were not updated and had incomplete data. Therefore, we studied 113 patients who were registered in the System based on the data of the irst semester of 2013.
The mean age was 57.3 ± 14.6 years, and eighty-two individuals (72.6%) presented an age equal or superior to 50 years old. The individuals were distributed according to the diagnosis and the data found in table 1.
It is possible to observe the predominance of female, Caucasian individuals, with education up to the elementary school incomplete and living with partners and children. Eighteen individuals were of the black race or medium brown and between these 83.3% presented diagnosis of HAS and 66.6% DM diagnosis.

Discussion
We studied 113 users, who were registered in 2013 in the HiperDia System of the municipality of Barra Bonita, State of São Paulo, representing 0.55% of the adult population of the municipality, in accordance with the data of the Brazilian Institute of Geography and Statistics (14). Regarding the amount of patients registered, the number of users included in the study was small, since the forms of the other patients were not completely illed. The studies of Oliveira and Jardim et Leal also showed a high number of forms missing basic information for the  All users took anti-hypertensive medicine, with mean values of systolic blood pressure (SBP) of 108 ± 44 mmHg and diastolic blood pressure (DBP) of 69 ± 27 mm Hg, and, regarding the value of capillary glycaemia, 69% presented a value out of normality.
Among them, eight individuals (10.3%) did not have a diagnosis of DM, but only SAH. The others are diabetic, which suggests they are not controlled since the glycaemia levels are high (13).
The patients' mean weight was 76.6 ± 16.6 kg, the mean height was 1.62 ± 9.2 m and the mean BMI was 29.8 ± 6.2 kg/m 2 in women and 28.4 ± 5.1 kg/ m 2 in men. Regarding the abdominal circumference measure (AC), 95.7% of the women and 72.1% of the men presented AC above normal. The AC mean was 102 ± 14 cm in women and 101 ± 12 cm in men.
The risk factors and the complications presented by users, according to the diagnosis, are on Table 2. It is possible to observe that most patients did not present Family history nor complications, 19.5% are smokers, 51.4% sedentary and 44.3% are overweight and obese. case of the diabetic patients, the family collaborates with a better glycemic control (25).
The BMI of women and men characterized overweight. The excess of body mass is a predisposing factor for the SAH, and can be responsible for between 20 and 30% of the cases. It is known that 75% of men and 65% of women present SAH directly associated with overweight and obesity (26). Obesity is commonly associated with DM2. The reduction of weight with a hypo caloric diet increases the tolerance to glucose and sensitivity to insulin, and the practice of regular exercises increases the action of the insulin (27).
According to the criteria of the VI Brazilian Guidelines on Hypertension (26), 95.7% of women and 72.1% of men of the present study presented an inadequate AC and, consequently, an increased cardiovascular risk. Studies were developed and the evidences of an association of the abdominal obesity with a bigger prevalence of morbidities are being conirmed. The android fat distribution, which is a characteristic of central or abdominal obesity, has been more strongly associated with the bigger prevalence of DM, cardiovascular diseases and SAH (28 -30).
The risk factors that determine and/or in luence the development of the SAH and the DM are innumerable. Some are inherent to the individual (age, gender and race) and others are related to the life style (smoking, sedentarism, obesity). In accordance with the literature, the family histories are considered relevant factors for the development of such diseases. Freitas and Sherer (31) af irmed the family history is a risk factor that cannot be medicated and, therefore, its fast recognition is essential for the analysis of individuals in relation to cardiovascular risks. In the present study, 41.6% of the patients presented a family history of SAH and/or DM.
According to the data of the National Institute of Cancer, smoking is considered the main preventable cause of death, and it duplicates the risk of development of cardiovascular diseases; 30% of the cases are attributed to the number of cigarettes smoked per day (32). Studies show a greater variation and elevation of the arterial pressure in the hypertensive smokers compared to the nonsmokers (33). In our studied population, 19.4% were smokers. Miranzi et al. (20) observed similar results, they observed that 19.4% of the hypertensive were smokers, among who, 66.7% were women. Other Brazilian studies also presented similar results (34,35). evaluation of the health condition of the diabetic and hypertensive (15,16).
From the total of the users analyzed, 81.4% presented a diagnosis of SAH and 59.3% of both SAH and DM. In the same direction, Lima et al. (17) noticed that, in their study 69.2% were hypertensive and 26.1% were diabetic hypertensive. It is known that the individual, who presents one of the pathologies mentioned, has a greater probability of developing the other one (1). As the SAH is associated with a higher degree of insulin resistance and the antihypertensive medicine can aggravate this condition, the hypertensive becomes more susceptible to develop diabetes (18).
A total of 72.6% of the analyzed individuals presented an age equal or superior to 50 years old. It is known that there is a directly proportional relation between the age and the development of chronic-degenerative diseases: the higher the age, the greater the possibility of developing cardiovascular complications (19).
In the present study, it is possible to observe a predominance of the female gender (62%). Corroborating with the results, Miranzi et al. (20) af irmed that this can be associated with the biggest amount of women in the world population. Zaitune et al. (21) reported women can have a greater probability of developing SAH and/or DM as they normally present a better perception of the diseases due to self-care and for searching more medical assistance than men.
Out of the total of individuals, 93 were Caucasians. Eighteen individuals were black or and, among these, 83.3% presented a diagnosis of SAH and 66.6% presented a diagnosis of DM. Ferreira and Ferreira (8) explain this high prevalence of pathologies among the black and brown individuals is due to ethical or socioeconomical factors presented by this population.
Studies show the level of education of the patients of the HiperDia can be in its majority considered low, and suggest the social inequality in the presence of chronic conditions. To know the level of education of these individuals may contribute to the planning of educational activities for the patient´s and their families` integral care (22 -24). We proved the indings of the studies as, in our study, we found 44.3% of the patients with an incomplete basic education.
Regarding the familiar situation, 94.7% of the patients lived with other people, which corroborates with the study of Ferreira and Ferreira (8), in which 90% of the individuals did not live alone. It is known that there is a narrow association of the treatment success with the familiar support, and that, in the Currently, the population presents very bad life habits (inadequate feeding, obesity and sedentarism), which favors the high incidence and prevalence of DM and SAH (36,37). Moreira et al. (38) claim that the overweight and the sedentarism are constantly found in studies on cardiovascular risk factors, since they are consequences of a consumerist society, in which feeding occurs in a fast and practical way and the daily activities demand minimums efforts to be executed. In our study, it was observed that 51.3% of the patients are sedentary and 44.3% present overweight or obesity. The lack of physical activity is estimated to be annually responsible for 10% to 16% of the DM cases and 22% of the ischemic illnesses (39).
The presence of complications in these patients can be associated with the lack of control of the SAH and of the DM regarding the EVA (11.5%), the kidney disease (13.3%) and, particularly, the AMI (11.5%). This makes us re lect about the association of the cares of the Family Health Units´ team and the PSF that will have to be intensi ied during the monitoring of these patients. Freire et al. (40) assessed 17 individuals with DM2 of the PSF from Presidente Prudente (SP) and reported the patients need more information and programs to prevent DM complications, predisposing alterations to amputations and other complications. Ferreira and Ferreira (8) observed in their study that the AMI (81.3%), the EVA (8%) and the kidney disease (9.9%) are the complications that are more often observed in patients with DM2. In 2004, Toscano (36) observed that 33% of the diagnosis of chronic kidney failure in Americans was attributed primarily to the DM, in which half were due to DM2.
In our study, one of the complications, the diabetic foot, was present in 7.1% of the patients who presented SAH and DM. According to Vieira-Santos et al. (41), the diabetic foot represented 9% of a sample of 1,374 diabetic people cared for in the Family Health Units of the municipality of Recife/PE, Brazil. In their study, Nunes et al. (42) observed that 55% of the diabetic hospitalized in the State of Sergipe, Brazil, with ulcerated feet, evolved into some type of amputation of the lower limbs, and 59% of them represented female individuals with an age of 61 years old.
The analysis of the data of the HiperDia of the municipality of Barra Bonita/SP showed that, when the patients arrived at the Basic Health Units (UBS), they already presented associated complications and a likely unsatisfactory metabolic control. Therefore, a bigger attention of the health professionals in relation to preventive measures is necessary.
It is important to highlight that the data collected in the HiperDia System cannot be controlled by the researcher, since they are illed by the employees of the UBS, with eventual typing mistakes, imperfections in the system that dif icult the exportation of data and the lack of information. Moreover, when the covering of the HiperDia System is analyzed, it is veriied that the municipality has presented dif iculties in standardizing the ideal estimate of DM prevalence because many patients` registration is outdated or they do not look for the public service. Therefore, we suggest the development of future studies that approach, in a deeper way, the possible reasons that can justify such facts.

Conclusion
The epidemiologic pro ile of the patients registered in the HiperDia System of the municipality of Barra Bonita/SP was characterized by: A mean age of 57.3 years, a predominance of the female gender, Caucasians; a low level of education; 19.5% smokers; most sedentary and 44.3% overweight and obese. More than the half of the patients presented a concomitant diagnosis of SAH and DM.
Epidemiological studies must be stimulated as they show the importance of establishing public health programs that aim to fortify changes in the life style, ighting the risk factors involved with the genesis and complications of the SAH and the DM. Thus, this type of study allows the physiotherapist to identify and follow problems that need a continuous attention and, after that, propose promotional, preventive, healing and rehabilitating actions, that is, a performance to an integral health, in contrast to the traditional and medicalized method, which is fragmented, hospitalcentered and based on the social exclusion.