STUDIES ON DIABETIC PATIENTS IN PRIMARY CARE

Objective: to analyze the scientific productions about diabetic patients in Primary Care. Method: integrative review carried out in the Lilacs, Medline and BDENF databases, from August 2016 to January 2017, in search of articles published in the last ten years in Portuguese that deal with diabetic patients in Primary Care. A bibliographic analysis was performed, as well as an exploratory and critical reading of the 14 selected studies. Results: problems such as difficulty in obtaining consultations, lack of medication in the Health Units and physical examination / unsatisfactory anamnesis, as well as an increase in the incidence of the disease as age progression and increased risk for cardiovascular diseases in diabetic patients were evidenced. Conclusion: the need for investment and development of Public Health in Brazil is evident. The importance of professional qualification is appreciated, in order to strengthen the assistance and educational actions in the Family Health Strategy, aiming at the higher quality of life of the patients. Thus, the study contributes to the areas of teaching, research and assistance by expanding knowledge in the area and stimulating investments and studies in this scenario. Descriptors: Diabetes Mellitus; Primary Health Care; Primary Prevention; Health Promotion; Family Health Strategy; Family Health. RESUMO Objetivo: analisar as produções científicas sobre pacientes diabéticos na Atenção Primária. Método: revisão integrativa realizada nas bases de dados Lilacs, Medline e BDENF, no período de agosto de 2016 a janeiro de 2017, em busca de artigos publicados nos últimos dez anos, em português, que versassem sobre os pacientes diabéticos na Atenção Primária. Foi realizada a análise bibliográfica, além de leitura exploratória e crítica das 14 pesquisas selecionadas. Resultados: evidenciaram-se problemas como dificuldade em conseguir consultas, falta de medicamentos nas Unidades de Saúde e exame físico/anamnese insatisfatório, além de relato do aumento da incidência da doença conforme progressão da idade e risco aumentado para doenças cardiovasculares em pacientes diabéticos. Conclusão: é evidente a necessidade de investimento e desenvolvimento da Saúde Pública no Brasil. Percebe-se a importância da capacitação dos profissionais, a fim de fortalecer a assistência e as ações educativas na Estratégia de Saúde da Família, visando à maior qualidade de vida dos pacientes. Desse modo, o estudo contribui para as áreas de ensino, pesquisa e assistência ampliando o conhecimento na área e estimulando investimentos e estudos nesse cenário. Descritores: Diabetes Mellitus; Atenção Primária à Saúde; Prevenção Primária; Promoção da Saúde; Estratégia Saúde da Família; Saúde da Família. RESUMEN Objetivo: analizar las producciones científicas sobre pacientes diabéticos en la Atención Primaria. Método: una revisión integradora realizada en las bases de datos LILACS, MEDLINE y BDENF, de agosto 2016 a enero 2017, en busca de artículos publicados en los últimos diez años en portugués, que abordasen sobre pacientes diabéticos en Atención Primaria. Se realizó el análisis bibliográfico, además de lectura exploratoria y crítica de las 14 encuestas seleccionadas. Resultados: se evidenciaron problemas como dificultad en conseguir consultas, falta de medicamentos en las Unidades de Salud y examen físico / anamnesis insatisfactorio, además de relato del aumento de la incidencia de la enfermedad conforme progresión de la edad y riesgo aumentado para enfermedades cardiovasculares en pacientes diabéticos. Conclusión: es evidente la necesidad de inversión y desarrollo de la Salud Pública en Brasil. Se percibe la importancia de la capacitación de los profesionales, a fin de fortalecer la asistencia y las acciones educativas en la Estrategia de Salud de la Familia, buscando la mayor calidad de vida de los pacientes. De este modo, el estudio contribuye a las áreas de enseñanza, investigación y asistencia, ampliando el conocimiento en el área y estimulando inversiones y estudios en ese escenario. Descriptores: Diabetes Mellitus; Atención Primaria de Salud; Prevención Primaria; Promoción de la Salud; Estrategia de Salud Familiar. Masters student, Professional Master's Program in Teaching in Health. Fluminense Federal University / UFF. Niterói (RJ), Brazil. E-mail: juliane_jasmim@hotmail.com ORCID iD: https://orcid.org/0000-0002-4404-8263; PhD, Fluminense Federal University / UFF. Niterói (RJ), Brazil. E-mail: gisellaqueluci@yahoo.com.br ORCID iD: https://orcid.org/0000-0003-0496-8513 INTEGRATIVE REVIEW ARTICLE Jasmim JS, Queluci GC. Studies on diabetic patients... English/Portuguese J Nurs UFPE on line., Recife, 12(4):1072-84, Apr., 2018 1073 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i4a231093p1072-1084-2018 Diabetes Mellitus (DM) is a disease that has been growing epidemiologically over the years and is now considered a public health problem. It is a non-transmissible chronic disease that has been increasing its importance due to its increasing prevalence. The treatment is carried out through pharmacological and non-pharmacological measures to control glycemic levels in order to avoid acute and chronic complications, promote quality of life and reduce mortality.

2] It is a non-transmissible chronic disease that has been increasing its importance due to its increasing prevalence. Diabetes Mellitus is a serious chronic disease characterized by high blood glucose level, hyperglycemia, resulting from the defect in insulin secretion and / or its action. 5igorous metabolic control, combined with preventive and curative measures, can prevent or delay the chronic complications of the disease by improving the quality of life of the individual.These measures involve changes in the patient's lifestyle and the primary level of health is the precursor base of this care. 6e Family Health Program (FHP) was implemented in Brazil in 1994 by the Ministry of Health, with the objective of reorganizing care practice, starting with basic care, replacing the traditional model of curative assistance for health promotion and prevention.Over the years, this program has undergone several modifications and today is called the Family Health Strategy. 6n-communicable diseases and grievances (NCDG) are now considered by the United Nations (UN), a growing epidemic around the world.In 2010, they were responsible for 58.5% of all deaths. The Brazilian population has experienced a rapid demographic, epidemiological and nutritional transition.The nutritional transition is characterized by the current predominance of a low-fiber diet and high levels of sugar and saturated fatty acid consumption, associated with the high prevalence of sedentary lifestyle.These factors contribute to the increased incidence of type II diabetes.In the last two decades, diabetes mortality in the Brazilian population, aged between 30 and 70 years, increased by 8%.Among the elderly (60 years or older), this increase was higher, corresponding to 18%.The Ministry of Health considers that "healthy living habits are the basis of diabetes treatment, on which pharmacological treatment may or may not be added."These habits include regular physical activity, healthy eating and weight control, as well as avoiding smoking and excessive consumption of alcoholic beverages. 7ter initiating research on the health and care of diabetic patients in the Family Health Strategy (FHS) to develop the master's thesis, the researcher noticed the existence of few studies that address such content.Therefore, this integrative review will focus on an analysis of the existing studies that address the diabetic patients of the FHS in Brazil in the last decade.
Thus, the justification for this study is due to the low number of studies that address the health and care provided to these patients in the FHS.It is necessary to deepen the knowledge and studies in this scope to guide interventions that improve the care related to these patients and, consequently, their quality of life.The integrative review allows the use of evidence present in numerous studies through the analysis of relevant research within the subject of interest.This method allows the elaboration of a conclusion from results found in several studies that investigated equivalent problems.In this way, it provides the production of knowledge that can be applied in several practical fields, making it possible to solve problems and carry out new studies. 9-

OBJECTIVE
used were: studies carried out in the last ten years; texts in Portuguese; scientific articles addressing the descriptors searched in the Virtual Health Library (VHL) inserted in the DeSC and studies carried out in Brazil.The exclusion criteria used were: review articles and experience reports; articles published more than ten years ago and do not correspond to the evidenced descriptors and articles of studies carried out outside Brazil. 10 should be noted that, for the search, the PICO strategy was used.However, in this study, since there was no comparison, IOP was used: P -patient / problem; I -intervention; O -result / outcome.The PICO strategy represents an acronym for Patient, Intervention, Comparison, and Outcomes.Within the EBP (Evidence Based Practice), these four components are the fundamental elements of the research question and the construction of the question for the bibliographic search of evidence.In this research, we used, for P, diabetic patients; for I, Analysis of the studies performed on these patients in the Family Health Strategy and, for O, analysis and understanding of the main results found. 11 the third stage, the articles were selected according to the previously defined concepts.The bibliographic analysis and the exploratory and critical reading of the selected studies were carried out, defining the information that should be extracted from each article and categorized in a synoptic table.The information is organized and summarized forming a database of easy access to present the characteristics and the main conclusions of each study.In the fourth step, the articles included in the integrative review are critically evaluated and correlated.In the fifth stage, the interpretation and discussion of the results occurs.And in the sixth and final stage, the review and synthesis of the knowledge produced about the theme.In figure 1, it can be observed that the quantitative of bibliographic productions related to the study database.In the first column, the database in which the search was carried out and the number of files related to the search descriptors in the following columns are observed.In the last column, the quantitative by magazine of the research is observed, by associated descriptors, totaling 33 articles.In the flowchart below, the quantitative of the associated descriptors after the analysis is inferred, according to the inclusion and exclusion criteria mentioned above, in addition to the exclusion of three articles repeated in the selected journals, totaling 14 articles that make up the integrative review.In the flowchart figure 2, these steps can be visualized, since it represents the path taken when searching the study material.In figure 2 The organization of the data was made from the elaboration of a structured instrument (synoptic table) containing: title of the article; kind of study; year of publication; authorship; newspapers; level of evidence and main results.The process of analysis of the 14 selected articles occurred through an exploratory and critical reading of the same.The study evaluated the assistance to the FHP user population of the municipality with Diabetes mellitus and Systemic arterial hypertension.It was detected that the FHP increased the population's access to health, and the satisfaction of the users was positive, but there was a complaint of lack of medication, besides incomplete anamnesis and unsatisfactory physical exams.
It is perceived that there should be more attention to the quality of health care, since the improvement of the same brings important consequences for the success of the treatment and to reduce damages.The study sought to know the clinical and social profile of hypertensive and diabetic patients who lacked the consultations and to identify the reasons for the absence.The profile detected was 87.8% women, but the sample had 43 women and six men, so it does not allow to affirm that they lack more than men.Schooling and social and economic situation presented were low.The reasons detected were: appointments at the day, forgetting the date and other reasons not specified.

Chronic complications of type 2 diabetic patients attended at the
The worsening of SAH and DM and its complications is related to the lack of adherence to the treatment.Admission to the consultations is positive adherence to treatment.The gender gap can be justified because of the greater demand of women for health services and their greater concern with health.Low schooling may represent difficulties in the understanding of the orientations made by the professionals, compromising the follow-up of the treatment.These patients need continuous follow-up of a multiprofessional team to prevent complications and the evolution of the disease.

Nursing in focus 3
The study evaluated the quality of life and the perception of the disease in patients with Diabetes mellitus attended at the ESF of Aragarças-GO.The study concluded that the perception of severity of DM is related to the impairment of quality of life.Most are unaware of the severity of the disease.
In the study the frequency of association between diabetes and hypertension was high, as well as all domains of quality of life were affected by the disease, especially in diabetic patients with the perception about the disease involved.The patient's perception of the disease as severe, the awareness of its chronicity, the possible complications, experiencing this reality reflects in the physical, social and psychoemotional affecting the quality of life of the individual.In this study there was also a predominance of females in the sample.
It is necessary to strengthen the educational process in primary health care to improve the behavior of individuals with diabetes.The study suggests that actions within the FHS are not enough to promote physical activity, more effective actions should be taken to stimulate this practice and better reorganize the performance of primary care to improve access to these patients' consultations.There was medium to low access, and the difficulty for some users to buy the drugs.In addition, the results lead to a reflection on the potentialities and difficulties resulting from decentralization for small municipalities, considering that despite the decentralization avoid large displacements of the population, it generates difficulties in organizing and updating the knowledge of health professionals.Given these facts, the study points to the need to strengthen strategies to favor access to medicines in the municipalities of the State of English/Portuguese J Nurs UFPE on line., Recife, 12(4):1072-84, Apr., 2018 1080 expenditure of R $ 18.30, R $ 14.00 and R $ 27.61 for antihypertensive drugs, ADO and insulin respectively.

Analysis of access to drug treatment for hypertension and diabetes in the Family
Pernambuco.The study evaluates and guides patients with type 2 DM for diabetic foot and regular physical exercise to control the disease and prevent complications.Deformities, dry skin, calluses, dehydration, ulceration, cracks and brittle nails were found.The tactile sensitivity was mainly affected in the heel region and the vibratory sensitivity was absent in 5% of individuals.There was a decrease in functionality in ankle movements.Of the participants, 76% were sedentary and 24% were aware of the benefits of regular physical exercise.

Implementation
The implementation of physiotherapeutic actions in diabetics of a SAI was important to highlight the presence of risk factors for diabetes complications.It was found that FHS individuals need more information and programs to prevent complications of DM and present predisposing alterations to amputations.The educational process of DM in relation to hyperglycemia, diabetic foot and its complications is paramount in the prevention of morbidity and mortality.Such actions significantly reduce the onset of ulcers and possible amputations after the development of educational programs.Thus, the work of the health team is fundamental to achieve reductions in the prevalence of these complications.The objective of the study is to know the beliefs of patients with chronicdegenerative diseases on health and their influence on health care.In the study, a greater prevalence of hypertensive than diabetics was observed.The categories identified showed values: health, family and faith.And as beliefs: "health is everything", "illness is something bad" and "living with the disease for the rest of life."Beliefs about health care involved drug and food care.Health care involved: following the diet, performing physical activity and following the therapeutic regimen.
It is important that the professional when approaching and accompanying the patient is aware of their beliefs, so the importance of the link between the professional and the patient.This allows the nurse or any other professional to draw peculiar goals and according to the particularities of each patient.Studies show that, since the implementation of the Family Health Program in Brazil in 1994, the population's access to health services increased.The family became the object of attention, in the environment in which it lives, allowing an extended understanding of the health / illness process.The program includes actions to promote health, prevention, recovery, rehabilitation of diseases and more frequent injuries. 6wever, despite the expanded access, there are still many reports of complaints related to lack of medication, difficulty in obtaining consultations in the Health Units, in addition to unsatisfactory physical examination and anamnesis, showing that there are still many aspects to be improved in this field of Family Health. 6,7,126][7][8] It is important to point out that all these problems are found, still in the present day, in Public Health in Brazil.

English
In all the studies selected, the female sample was prevalent over the male, which allows us to infer that women seek health services more than men. 5,13,14It is important to act in the promotion of human health and increase the access to health services.Many of these men may be diabetic and unaware that they have the disease because they do not seek health professionals, nor do they perform routine tests to detect it.
In addition, studies have shown that the older the disease, the greater the prevalence of the disease, which may be justified by the increase in insulin resistance.Women have a longer life expectancy than men, that is, they live longer than men, and may be more affected by Diabetes, as their prevalence is higher according to age. 5, Women diabetics tend to have a higher percentage of body fat and BMI, lower cardiorespiratory fitness and level of physical activity, causing overweight and obesity, risk factors for the disease. 14 Lw education and low income present in the sample members justify the difficulty in understanding of the guidelines carried out by the team, as well as the follow-up of the treatment.6,13,15 Chronic diseases have a correlation with these variables, since the higher the educational level and economic capacity, the lower the incidence of complications due to the higher level of education.health care. Ol age, low schooling, and a high number of comorbidities undermine the treatment of the disease.15 In the studies that evaluated the complications of the disease, it was observed that most of the patients presented alterations and complications.5,8 In a study carried out, 58.9% of the sample presented at least one complication of the disease, and the prevalence of complications increases with age.This shows the importance of acting in the prevention of the disease to prevent it from establishing itself.The author cites some studies reporting that patients with type 2 DM have a four-fold increased risk of having peripheral vascular disease compared to nondiabetic patients.5 In addition to prevention, it is very important to guide those who are already diabetic about the importance of changing eating habits, practicing physical exercise and medication adherence to avoid complications and decrease quality of life.Studies have shown that patients who have control over the disease are less affected by the complications of the disease than the decompensated patients.DM directly affects the patient's quality of life at all levels, and most of these patients are unaware of the severity of the disease.Patients who underwent dietary changes had a reduction in fasting glycemia, glycated hemoglobin, cholesterol, and systolic and diastolic blood pressure, demonstrating the importance of diet and its efficacy.Physical exercise, diet and pharmacological treatment are considered the three main measures in the treatment of DM. 18,19 After analyzing the evidenced studies, it is possible to conclude that the assistance to diabetic patients in the Family Health Strategy still has many aspects and aspects to be improved.The problems due to lack of public sector investment are chronic and deserve greater attention from the responsible authorities.
There should also be greater attention to the quality of health care, both by professionals and patients.Discipline and attention to care reduces harm by generating a successful treatment.It is important to reinforce measures of actions in the health services that aim to reduce the risk factors and the impact of complications on the quality of life of the patients with DM, since the improvement of the health brings important consequences for the success of the treatment and reduction of damages and complications of the disease.The complexity of the treatment of DM requires that the health team is qualified for care, therefore it is necessary and primordial to carry out training programs and ongoing education with professionals to carry out quality care.

DISCUSSION
It is believed that this study will contribute in the areas of teaching, research and care, increasing the professionals' knowledge about DM in the FHT, besides increasing the knowledge of the patients about their pathology and stimulating educational actions in this scenario.Their understanding of the reality they have experienced and the assistance they have received in the last few years allows them to increase the interest of health professionals and the government in improving the quality of the service provided, providing care, raising awareness and training and qualifying professionals.

Figure 2 .
Figure 2. Flowchart of the methodological path taken to choose the articles to be analyzed.Niterói (RJ), 2016-2017.

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To analyze the studies on diabetic patients in Primary Care.
, one can observe the classification of level of evidence, according to the University of Oxford, of 2001.

of health services by diabetics covered by private plan in comparison to users of the Unified Health System in the city of Belo Horizonte, Minas Gerais, Brazil
J Nurs UFPE on line., Recife, 12(4):1072-84, Apr.,