Prevalence, management and control of diabetes mellitus and associated risk factors in primary health care in Portugal

Nuno Cortez-Dias, Susana Martins, Adriana Belo, Manuela Fiuza
Portuguese Journal of Cardiology: An Official Journal of the Portuguese Society of Cardiology 2010, 29 (4): 509-37

OBJECTIVE: To assess the prevalence, treatment and control of diabetes mellitus (DM) in primary health care users, to characterize associated cardiovascular (CV) risk factors and effectiveness of their treatment, and to estimate the clinical impact of DM on the occurrence of coronary artery disease (CAD) and stroke.

METHODS: The VALSIM Study was performed in a primary care setting and involved 719 general practitioners (GPs), based on stratified distribution and proportional to the population density of each region of mainland Portugal and the islands of Madeira and the Azores. A questionnaire on sociodemographic and clinical data (previous diagnosis of DM, CAD or stroke, antidiabetic and antihypertensive medication and statins) and laboratory tests (lipids and HbA1C) was applied by participating GPs to the first two adult patients scheduled for an appointment on a given day, and blood pressure (BP) was measured. DM was defined as fasting glucose of > or = 126 mg/dl or use of antidiabetic agents.

RESULTS: The study included 16,856 individuals (mean age 58.1 +/- 15.1 years; 61.6% women), of whom 3215 were identified as diabetic. The prevalence of DM adjusted for gender and age in primary health care users was 14.9%, higher in men (M: 16.8%; F: 13.2%), and increased with age. Among the diabetic population, 90.2% were being treated with antidiabetic drugs and 51.7% had HbA1C lower than 7%. Around 91% had high BP (> or = 130/80 mmHg or were taking antihypertensive medication), 39.5% were overweight, 45.1% were obese, 69.3% had abdominal obesity, 71.8% had metabolic syndrome (ATP III criteria), 12% presented CAD and 5% had past history of stroke. The association between these CV risk factors and DM was stronger in women, and the impact of DM on occurrence of CAD and stroke was also higher in women. Among diabetic hypertensives, 78.4% were being treated with antihypertensive drugs, but only 9.3% had BP < 130/80 mmHg (M: 9.5%; F: 9.1%). Of diabetic patients with CAD, 94.2% were taking antihypertensive medication, but only 9.8% had controlled BP (M: 13.7%; F: 6.1%). Although 59% of the diabetic population were being treated with statins, only 6.7% had total cholesterol < 200 mg/dl, triglycerides < 150 mg/dl and HDL-cholesterol > 60 mg/dl. Of diabetic patients with CAD, 76.5% were being treated with statins, but only 29.4% had total cholesterol < 175 mg/dl (M: 34.2%; F: 24.1%).

CONCLUSIONS: The management of DM in a primary care setting in Portugal can and should be improved, since 9.8% of patients are not treated and 48.3% are not controlled. DM has a considerable clinical impact due to its strong association with CAD and stroke. The risk of stroke and CAD is much higher in diabetic women, due firstly to a stronger association of DM with other risk factors in women, and secondly to less aggressive treatment.

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