Abstracts

INTRODUCTION

Population aging is one of the greatest challenges in public health, particularly in medium-income countries.^aa Camarano AA, Kanso S. Perspectivas de crescimento para a população brasileira: velhos e novos resultados. Brasília (DF): Instituto de Pesquisa Econômica Aplicada; 2009. There has been a significant increase in the older population (≥ 60 years) in Brazil over the last decades: from 1.7 million in 1940 to 20.5 million in 2010 (10.8% of the Brazilian population).^aa Camarano AA, Kanso S. Perspectivas de crescimento para a população brasileira: velhos e novos resultados. Brasília (DF): Instituto de Pesquisa Econômica Aplicada; 2009.^,bb Instituto Brasileiro de Geografia e Estatística. Censo 2010. Brasília (DF); 2010 [cited 2014 Feb 28]. Available from: http://www.censo2010.ibge.g.,ov.br/sinopse/webservice

Moreover, Brazil is going through a process of epidemiological transition. Chronic diseases, which are typical of aging, are in focus in the context of public health. Diabetes mellitus is one of the main diseases that affect the older population. Its increasing prevalence and high morbidity and mortality make it a global epidemic.¹⁰10  Lima-Costa MF, Filho AIL, Matos DL. Tendências nas condições de saúde e uso de serviços de saúde entre idosos brasileiros: um estudo baseado na Pesquisa Nacional por Amostra de Domicílios (1998, 2003). Cad Saude Publica. 2007;23(10):2467-78. DOI:10.1590/S0102-311X2007001000021^,2323  Vinicor F. Is diabetes a public health disorder? Diabetes Care. 1994;17(Suppl 1):22-7.

Diabetes is challenging for the health systems worldwide. Population aging, growing urbanization, and intensification of globalization as well as the adoption of unhealthy lifestyles and industrialized diets are the main causes for the increased incidence and prevalence of the disease.¹⁰10  Lima-Costa MF, Filho AIL, Matos DL. Tendências nas condições de saúde e uso de serviços de saúde entre idosos brasileiros: um estudo baseado na Pesquisa Nacional por Amostra de Domicílios (1998, 2003). Cad Saude Publica. 2007;23(10):2467-78. DOI:10.1590/S0102-311X2007001000021

The number of patients with diabetes worldwide exceeds 180 million and is estimated to reach 350 million in 2025.²³23  Vinicor F. Is diabetes a public health disorder? Diabetes Care. 1994;17(Suppl 1):22-7. According to the Ministry of Health, over 10 million individuals in Brazil have diabetes, of which approximately 33.0% are between 60 and 79 years of age.^cc Portal Brasil. Saúde do Idoso. Brasília (DF); 2012 [cited 2014 Feb 28]. Available from: http://www.brasil.gov.br/sobre/saude/saude-do-idoso/diabetes

The aim of this study was to analyze the prevalence of diabetes among older people and the adopted control measures.

METHODS

This cross-sectional study used data from Health Surveys in the Municipality of Sao Paulo, SP, Southeastern Brazil, ISA-Capital 2003, and ISA-Capital 2008. The addressed topics were related the individual’s overall health (lifestyle, living conditions, state of health, and use of health services).

In the ISA-Capital 2003, 3,357 individuals (872 older adults) were interviewed. The sample was stratified by groups in two stages: census and households. Sixty census sectors were drawn based on the PNAD-2002 sample (National Household Sample Survey). The sectors were drawn into three strata, according to level of schooling of the head of the family, measured by the percentage of those who had a university degree: < 5.0%, 5.0%-24.99%, and ≥ 25.0%.

The planned minimum sample size was 420 individuals for each domain, i.e., sex and age: < 1 year, 1-11 years; 12-19 years (males and females); 20-59 years (males and females); and ≥ 60 years (males and females). This was based on an estimated prevalence of 50%, a confidence level of 95% (95%CI), a sampling error of 0.06, and a design effect of 1.5.

In the ISA-Capital 2008, 3,271 individuals (924 older adults) were interviewed, and the stratified sampling was performed by groups in two stages: census sectors (70 sectors) and households. The sample was formed by eight demographic domains, as in the survey of 2003. The sample size varied between 300 and 780 domains. These were calculated considering an estimated prevalence of 50.0%, 95%CI, a sampling error between 0.04 and 0.07, and a design effect of 1.5.

We used the sampling domains of ≥ 60 years for both the male and female sexes from the two surveys.

Data were obtained by means of a questionnaire composed of groups of topics with specific questions – mainly closed questions with pre-established alternatives. The questionnaires were administered by trained interviewers and answered by the older individuals themselves.

The dependent variable was the presence of self-reported diabetes.

The independent variables were demographic and socioeconomic characteristics, such as sex (male and female), age (60-69 years, 70-79 years, and ≥ 80 years), ethnicity (Caucasian and non-Caucasian), marital status (married, stable relationship, single, separated/divorced, widower), level of schooling (years of study: 0-3, 4-7, ≥ 8), occupation (with an activity, without an activity, unemployed), per capita income (minimum salary: ≤ 0.5, > 0.5-2.5, ≥ 2.5). The following parameters were also analyzed: knowledge and practice of measures of diabetes control (diet, regime to lose/maintain weight, physical activity, routine use of insulin, use of insulin on a need basis, routine use of oral hypoglycemic agents, use of oral hypoglycemic agents on a need basis, no measures, and others), complications (vision problems, kidney problems, and circulatory problems), and the use of health services to control diabetes (flu and pneumonia immunization, proximity of the vaccination center to the older person’s home, and type of service: public or private).

Association between demographic/socioeconomic variables and the presence of diabetes was estimated using the Chi-square test, and the level of significance was set as 5%.

Prevalences and 95%CI were compared to evaluate the control practices and use of health services by diabetic patients. The overlap between the confidence intervals was determined for the two distinct groups.

The difference between the two years was considered significant when there was no overlap between the confidence intervals. Otherwise, the databases from 2003 and 2008 were combined (combined database) using the statistical software Stata 11.0 and the append command.

The combination of the databases was necessary to determine if small overlaps between confidence intervals were statistically significant. To assemble the information contained in both databases in a single database, all the variables kept the same name and answer category and a new variable was created to identify from which database the observation originated.¹⁷17  Segri NJ, Francisco PMSB, Alvez MCGP, Barros MBA, Cesar CLG, Goldbaum M, et al. Práticas preventivas de detecção de câncer em mulheres: comparação das estimativas dos inquéritos de saúde (ISA - Capital) e vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico (VIGITEL - São Paulo). Rev Bras Epidemiol. 2011;14 Suppl 1:31-43. DOI:10.1590/S1415-790X2011000500004 The association was performed using Pearson’s Chi-square (Rao-Scott). The variables without overlap between the confidence intervals were not tested.

The data analysis was performed using the statistical software Stata 11.0 and the survey module, which takes into consideration the effects of complex sampling.

The present study was approved by the Ethics Committee of the Faculdade de Saúde Pública of the Universidade de São Paulo (Opinion 48.299, de 2012).

RESULTS

Diabetes mellitus was reported by 17.6% (95%CI 14.9;20.6) of the older individuals who answered the 2003 survey and by 20.1% (95%CI 17.3;23.1) of those who answered the 2008 survey. This increase tended to be significant. There was a significant association between self-reported diabetes and low income (in 2003) and between self-reported diabetes and low levels of schooling (in 2008) (Table 1).

In 2003, 52.1% of the older adults with diabetes mentioned following a diet. These individuals were mainly women (73.8%; p = 0.029). The percentage of older individuals with diabetes following a diet in 2008 was 61.0%. In both years, > 90.0% of the older adults stated not following a regime to lose/maintain their weight. There was a low frequency of physical activity, with > 85.0% of the older people stating that they did not perform any physical activities (p = 0.029), in both years (Table 2).

The prevalence of routine use of insulin was similar in both years; it was more prevalent in women: 88.2% (p = 0.010) of the older women with diabetes in 2003 and 81.4% (p = 0.016) in 2008. Hardly any older individuals (< 1%) used insulin on a need basis. The prevalence of routine use of oral hypoglycemic agents was 61.0% in 2003 and 71.8% in 2008, which represented a significant increase during this period. In both years, hardly any older individuals (< 3%) used oral hypoglycemic agents on a need basis. The options “no measures” and “other” showed prevalences of < 10.0% in both years (Table 2).

In 2003, 23.5% of the older adults said that they had some form of complication from diabetes; and in 2008, this percentage was 28.9%. Vision problems were more prevalent than kidney problems (63.6% in 2003 and 72.3% in 2008). In 2003, the prevalence of vision problems in older diabetic patients was higher in married individuals (72.5%; p = 0.002) and in retired individuals (78.2%; p = 0.038). In 2008, the prevalence of vision problems was higher in non-Caucasian individuals (35.8%; p = 0.027). The prevalence of kidney problems was 15.4% in 2003 and 38.5% in 2008 (this difference was statistically significant (p = 0.046)) (Table 3) and was associated with low schooling levels in 2003 (p = 0.048) and in 2008 with the male sex (56.5%) (p = 0.004). The prevalence of circulatory problems was 34.4% in 2003 and 52.3% in 2008 and was higher in the male older individuals (50.0%) in 2008 (p = 0.012).

Approximately 70.7% of the older adults were vaccinated against the flu in 2003 and 66.9% in 2008 (Table 4). The majority used the public health service to receive the vaccine (> 95.0% in both years), and in 2008, public health service was the most used by the older individuals with low income (p = 0.008). Most stated having received the vaccine at the health center closest to their home. The proximity of the vaccination center to the patients’ homes was associated with low income (p < 0.001 and p = 0.002, in 2003 and 2008, respectively) and with low schooling levels (p = 0.003 in 2003).

In 2003, 28.9% of the older adults with diabetes reported having received the vaccine against pneumonia; and in 2008, this percentage was 24.3%. In both years, > 95.0% of individuals stated that they received this vaccine at public health centers and at the center that was closest to home (Table 4). In 2008, this fact was associated with the level of schooling: it was higher in individuals with ≥ 8 years of study (p = 0.032).

DISCUSSION

The prevalence of self-reported diabetes in the older adults was 17.6% in 2003 and 20.1% in 2008. The prevalence of diabetes was 17.9% in Sao Paulo, according to the SABE Project⁸8  Lebrão ML. Condições de saúde. In: Lebrão ML, Laurenti R. SABE – Saúde, Bem-estar e Envelhecimento. O Projeto Sabe no Município de São Paulo: uma abordagem inicial. Brasília (DF): Organização Pan-Americana da Saúde; 2003. p. 73-91. (Health, Well-being and Aging) and 14.6% in Bambuí, SP, according to the Project Bambuí¹⁶16  Passos VMA, Barreto SM, Diniz LM, Lima-Costa MF. Type 2 diabetes: prevalence and associated factors in a Brazilian community – the Bambuí health and aging study. Sao Paulo Med J. 2005;123(2):66-71. DOI:10.1590/S1516-31802005000200007 (population-based cohort study on the health of the older people, which used laboratory tests to determine the presence of the disease, conducted in 1997).

The increase in the prevalence of diabetes from 2003 to 2008 may be due to the higher number of diagnosed cases of diabetes or to the actual expansion of the disease. The higher number of diagnosed cases may be the result of the introduction of HiperDia,²²22  Toscano CM. As campanhas nacionais para detecção das doenças crônicas não-transmissíveis: diabetes e hipertensão arterial. Cienc Saude Coletiva. 2004;9(4):885-95. DOI:10.1590/S1413-81232004000400010 which allows to monitor patients with diabetes registered in basic health units. HiperDia was established between 2001 and 2003 and involved campaigns of diabetes screening, diagnosis confirmation, and treatment initiation. The expansion of the disease results from the increase in the prevalence of obesity in the older population. Obesity is the risk factor for diabetes incidence and hinders its treatment when the disease is already established. The prevalence of obesity is higher in the diabetic population.⁴4  Gomes MB, Giannella Neto DG, Mendonça E, Tambascia MA, Fonseca RM, Réa RR, et al. Prevalência de sobrepeso e obesidade em pacientes com diabetes mellitus tipo 2 no Brasil: estudo multicêntrico nacional. Arq Bras Endocrinol Metab. 2006;50(1):136-44.DOI:10.1590/S0004-27302006000100019
https://doi.org/10.1590/S0004-2730200600... ^,77  Hippisley-Cox J, Pringle M. Prevalence, care and outcomes for patients with diet-controlled diabetes in general practice: Cross-sectional survey. Lancet. 2004;364(9432):423-8. DOI:10.1016/S0140-6736(04)16765-2

Income (in 2003) and level of schooling (in 2008) were significantly associated with diabetes, which indicates that the prevalence of diabetes among the older people was affected by socioeconomic factors. The Project Bambuí¹⁶16  Passos VMA, Barreto SM, Diniz LM, Lima-Costa MF. Type 2 diabetes: prevalence and associated factors in a Brazilian community – the Bambuí health and aging study. Sao Paulo Med J. 2005;123(2):66-71. DOI:10.1590/S1516-31802005000200007 and the study conducted in the city of Araraquara, SP, Southeastern Brazil,²⁰20  Silva RC, Simões MJ, Leite AA. Fatores de risco para doenças cardiovasculares em idosos com diabetes mellitus tipo 2. Rev Cienc Farm Basica Apl. 2007;28(1):113-21. also found significant associations between diabetes and low-income levels. Lima-Costa⁹9  Lima-Costa MF. Influence of the age and educational level on the use of preventive health care services: Health survey in the Metropolitan Area of Belo Horizonte, Minas Gerais State, Brazil. Epidemiol Serv Saude. 2004;13(4):209-15. (2004) suggests that schooling affects behaviors prejudicial to the health of older adults and that low levels of schooling are associated with the occurrence of chronic diseases and other dysfunctions.

The number of older individuals who followed a diet did not increase significantly. There was a significant difference between the sexes in 2003 with regard to diet, with a higher percentage of women following a diet. The results are in line with data from VIGITEL,¹²12  Malta DC, Silva SA, Oliveira PPV, Iser BPM, Bernal RTI, Sardinha LMV, et al. Resultados do monitoramento dos Fatores de risco e Proteção para Doenças Crônicas Não Transmissíveis nas capitais brasileiras por inquérito telefônico, 2008. Rev Bras Epidemiol. 2012;15(3):639-50. DOI:10.1590/S1415-790X2012000300017 in which women showed a higher intake of fruits, legumes, and vegetables and less intake of meat with excess fat. Moreover, the routine use of insulin was associated with the variable sex in both years. These results are similar to those obtained in other studies and suggest that women are more willing to undergo insulin treatment than men.⁴4  Gomes MB, Giannella Neto DG, Mendonça E, Tambascia MA, Fonseca RM, Réa RR, et al. Prevalência de sobrepeso e obesidade em pacientes com diabetes mellitus tipo 2 no Brasil: estudo multicêntrico nacional. Arq Bras Endocrinol Metab. 2006;50(1):136-44.DOI:10.1590/S0004-27302006000100019
https://doi.org/10.1590/S0004-2730200600...

The routine use of an oral hypoglycemic agent tended to be significant in the period under study, and it was the most frequent habit of the older diabetic population. The prevalence of the use of hypoglycemic agents by the older population was 64.7% in a survey conducted in Minas Gerais⁵5  Gontijo MF, Ribeiro AQ, Klein CH, Rozenfeld S, Acurcio FA. Uso de anti-hipertensivos e antidiabéticos por idosos: inquérito em Belo Horizonte, Minas Gerais, Brasil. Cad Saude Publica. 2012;28(7):1337-46. DOI:10.1590/S0102-311X2012000700012 in 2003.

Only one habit, among the most reported by the older diabetic patients (diet, use of oral hypoglycemic agents, and use of insulin), was related to health promotion and prevention of chronic diseases. Physical activity was not a frequent practice, although it increased over the period under analysis and despite the significant difference between 2003 and 2008. Physical exercise is essential for the control of the disease and is a part of its treatment.¹⁹19  Sigal RJ, Kenny GP, Wasserman DH, Castaneda-Sceppa C, White RD. Physical activity/exercise and type 2 diabetes: a consensus statement from the American Diabetes Association. Diabetes Care. 2006;29(6):1433-8. DOI:10.2337/dc06-9910

A study conducted in Minas Gerais showed similar results with regard to complications from diabetes, i.e., higher prevalence of vision problems in the older adults who lived with a partner, who were retired, and who were housewives.²¹21  Tavares DMS, Rodrigues FR, Silva CGC, Miranzi SSC. Caracterização de idosos diabéticos atendidos na atenção secundária. Cienc Saude Coletiva. 2007;12(5):1341-52. DOI:10.1590/S1413-81232007000500032 This complication was predominant in non-Caucasian individuals, which is in line with the results presented in the international literature.⁶6  Harris MI, Klein R, Cowie CC, Rowland M, Byrd-Holt DD. Is the risk of diabetic retinopathy greater in non-Hispanic blacks and Mexican Americans than in non-Hispanic whites with type 2 diabetes? A US population study. Diabetes Care. 1998;21(8):1230-5. DOI:10.2337/diacare.21.8.1230 Non-Caucasian individuals have higher blood pressure levels than Caucasian individuals, which is a risk factor for the development of the vision problems. According to data from the NHANES, the prevalence of vision problems in the non-Caucasian population is 46.0% higher than in the Caucasian population.⁶6  Harris MI, Klein R, Cowie CC, Rowland M, Byrd-Holt DD. Is the risk of diabetic retinopathy greater in non-Hispanic blacks and Mexican Americans than in non-Hispanic whites with type 2 diabetes? A US population study. Diabetes Care. 1998;21(8):1230-5. DOI:10.2337/diacare.21.8.1230

Differences with regard to kidney complications were observed between 2003 and 2008, which is in agreement with the Brazilian literature. A Brazilian study with data regarding the period between 2000 and 2004 demonstrated a prevalence of diabetic nephropathy of 15.0%,¹1  Cherchiglia ML, Machado EL, Szuster DAC, Andrade EIG, Acurcio FA, Caiaffa WT, et al. Epidemiological profile of patients on renal replacement therapy in Brazil, 2000-2004. Rev Saude Publica. 2010;44(4):1-10. DOI:10.1590/S0034-89102010000400007 whereas in 2009, it was 27.0% as per The Brazilian Dialysis Census of the Brazilian Nephrology Association.¹⁸18  Sesso RCC, Lopes AA, Thomé FS, Lugon JR, Burdmann EA. Censo Brasileiro de Diálise, 2009. J Bras Nefrol. 2010;32(4):380-4. DOI:10.1590/S0101-28002010000400007

Diabetes increases the risk of developing cardiovascular disorders. These conditions have a negative effect on the quality of life of older people with diabetes and can lead to death. A study conducted in Maringá, PR, over four 3-year periods (1979-1981, 1984-1986, 1990-1992, and 1996-1998) indicates diseases of the circulatory system as the principal cause of mortality in older individuals with diabetes.¹³13  Mathias TAF, Jorge MHPM. Diabetes Mellitus na população idosa em Município da região Sul do Brasil: um estudo de mortalidade e morbidade hospitalar. Arq Bras Endocrinol Metab. 2004;48(4):505-12. DOI:10.1590/S0004-27302004000400011

In 2003, 70.7% of older people with diabetes were vaccinated against the flu; in 2008 this percentage was 66.9%. The immunization program in the older population was initiated in the 1960s and was recommended by the World Health Organization. The minimum vaccination coverage goal established by the National Immunization Program was 70.0% until 2007 and was increased to 80.0% in the following year.^dd Portal Saúde. Saúde lança nesta 3ª feira Campanha Nacional de Vacinação contra gripe de 2012. Brasília (DF); 2012 [cited 28 Feb 2014]. Available from: http://www.brasil.gov.br/saude/2012/04/saude-lanca-nesta-3a-feira-campanha-nacional-de-vacinacao-contra-gripe-de-2012

More than 95.0% of the vaccinated older adults used the public health services to receive the vaccine, in both years. This fact was associated with low income. A study that used data from the SABE project¹¹11  Louvison MCP, Lebrão ML, Duarte YAO, Santos JLF, Malik AM, Almeida ES. Desigualdades no uso e acesso aos serviços de saúde entre idosos do Município de São Paulo. Rev Saude Publica. 2008;42(4):733-40. DOI:10.1590/S0034-89102008000400021 suggested a significant association between the use of public services and low income.

The centers where the patients received the flu vaccine were those closest to their homes. This result was statistically associated with low income and low schooling levels; moreover, it was similar to data obtained in a study²2  Costa JSD, Facchini LA. Utilização de serviços ambulatoriais em Pelotas: onde a população consulta e com que frequência. Rev Saude Publica. 1997;31(4):360-9. DOI:10.1590/S0034-89101997000400005 conducted in Pelotas, RS, Southern Brazil. The individuals who lived nearest to the health centers were those with lower incomes and lower education levels.

Vaccination against pneumonia was 28.9% in 2003 and 24.3% in 2008. Older diabetic patients are more susceptible to pneumonia because they are at greater risk for hyperglycemia, low immunity, reduced lung function, and other co-morbidities.³3  Falguera M, Pifarre R, Martin A, Sheiks A, Moreno A. Etiology and outcome of community-acquired pneumonia in patients with diabetes mellitus. Chest. 2005;128(5):3233-39. DOI:10.1097/MD.0b013e31827f602a

The majority of the older adults stated that they received the vaccine in the centers closest to their homes. Proximity of the vaccination centers to home was associated with the individuals’ level of schooling and the vaccination coverage was lower in those with low levels of education. The older patients with higher schooling levels showed better health status, better lifestyles, higher level of information, and better socioeconomic conditions, when compared to those with lower schooling levels.¹⁴14  Noronha KV, Andrade MV. Desigualdades sociais em saúde e na utilização dos serviços de saúde entre os idosos na América Latina. Rev Panam Salud Publica. 2005;17(5/6):410-8. DOI:10.1590/S1020-49892005000500013

The information used to estimate the prevalences were self-reported, i.e., laboratory tests were not used to confirm the diagnosis of diabetes. Previous studies have indicated that the validity of self-reported information varies according to the disease, the impairments and comorbidities, and the sociodemographic characteristics.¹⁵15  Okura Y, Urban LH, Mahoney DW, Jacobsen SJ, Rodeheffer RJ. Agreement between self-reported questionnaires and medical record data was substantial for diabetes, hypertension, myocardial infarction and stroke but not for heart failure. J Clin Epidemiol. 2004;57(10):1096-103. DOI:10.1016/j.jclinepi.2004.04.005 It is estimated that 50.0% of individuals with diabetes are not aware they have the disease, which remains asymptomatic until screening tests are performed or until disease-related complications occur.^ee Ministério da Saúde. Diabetes Mellitus. Brasília (DF); 2006. The analysis period was restricted to 5 years, according to the periodicity of the survey that was used.

Diabetes mellitus is a common and serious disease that causes financial burden to the patients as well as health services. Diabetes deserves special attention among the complex and challenging disorders that currently affect the society and the health systems; it is a public health problem. Programs to encourage practices of health promotion and healthy lifestyles should be implemented, because these have a positive effect on the quality of life of older individuals with diabetes. A reflection on the policies and measures aimed at this particular population are necessary to improve the care given to diabetic patients. Such actions are indispensible for the promotion of better living conditions and health among this population.

REFERENCES

Publication Dates

History