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Impacto de intervenções educativas na redução das complicações diabéticas: revisão sistemática

Impacto de intervenciones educativas en la reducción de las complicaciones diabéticas: revisión sistemática

RESUMO

Objetivo:

identificar na literatura evidências da efetividade e eficácia de intervenções educativas na redução de complicações metabólicas e/ou vasculares em adultos com diabetes mellitus.

Método:

revisão sistemática realizada nas bases de dados LILACS, IBECS, CUMED, CINAHL e Medline e na biblioteca on-line SciELO com estudos de 2004 a 2014.

Resultados:

incluídos 11 estudos (5 ensaios clínicos randomizados e 6 quase experimentais). Apenas pesquisas que analisaram complicações vasculares foram identificadas.

Conclusão:

dois ensaios clínicos mostraram eficácia na redução de complicações cardiovasculares, da catarata ou retinopatia e nefropatia e todos os estudos quase experimentais revelaram efetividade na redução das úlceras nos pés, da vasculopatia e da neuropatia periféricas e manutenção da função renal.

Descritores:
Educação em Saúde; Avaliação de Eficácia-Efetividade de Intervenções; Complicações Diabéticas; Diabetes Mellitus Tipo 1; Diabetes Mellitus Tipo 2

RESUMEN

Objetivo:

identificar en la literatura evidencias de la efectividad y eficacia de intervenciones educativas en la reducción de complicaciones metabólicas y/o vasculares en adultos con diabetes mellitus.

Método:

revisión sistemática realizada en las bases de datos LILACS, IBECS, CUMED, CINAHL y Medline, y en la biblioteca online SciELO, consultado estudios de entre 2004 y 2014.

Resultados:

fueron incluidos 11 estudios (5 ensayos clínicos randomizados y 6 cuasiexperimentales). Solamente fueron identificadas investigaciones que analizaron complicaciones vasculares.

Conclusión:

dos ensayos clínicos mostraron eficacia en la reducción de complicaciones vasculares, de la catarata o retinopatía y de la nefropatía; y todos los estudios cuasiexperimentales revelaron efectividad en la reducción de las úlceras de pie, la vasculopatía y la neuropatía periféricas, y en el mantenimiento de la función renal.

Descriptores:
Educación en Salud; Evaluación de Eficacia-Efectividad de Intervenciones; Complicaciones de la Diabetes; Diabetes Mellitus Tipo 1; Diabetes Mellitus Tipo 2

ABSTRACT

Objective:

To identify in the literature evidence of the effectiveness and efficacy of educational interventions in reducing metabolic and/or vascular complications in adults with diabetes mellitus.

Method:

A systematic review performed in LILACS, IBECS, CUMED, CINAHL and Medline databases and in the online library SciELO with studies published from 2004 to 2014.

Results:

Eleven studies were included (5 randomized clinical trials and 6 quasi-experimental). We only identified studies that analyzed vascular complications.

Conclusion:

Two clinical trials demonstrated efficacy in reducing cardiovascular complications, of cataract or retinopathy and nephropathy and all the quasi-experimental studies showed effectiveness in reducing feet ulcers, peripheral neuropathy and vasculopathy, and maintenance of kidney function.

Descriptors:
Health Education; Evaluation of the Efficacy-Effectiveness- of Interventions; Diabetic Complications; Diabetes Mellitus Type 1; Diabetes Mellitus Type 2

INTRODUÇÃO

As doenças crônicas não transmissíveis (DCNT), como o diabetes mellitus (DM), a hipertensão arterial e a doença pulmonar obstrutiva crônica, ocupam as primeiras posições nas estatísticas de mortalidade mundial: 73% dos óbitos em 2020 serão causados por tais doenças(11 Oliveira-Campos M, Rodrigues-Neto JF, Silveira MF, Neves DMR, Vilhena JM, Oliveira JF, et al. The impact of risk factors of non-communicable chronic diseases on quality of life. Ciênc Saúde Colet [Internet]. 2013[cited 2014 Mar 01];18(3):873-82. Available from: http://www.scielosp.org/pdf/csc/v18n3/33.pdf
http://www.scielosp.org/pdf/csc/v18n3/33...
). Aproximadamente 347 milhões de pessoas no mundo têm DM, sendo 90% do tipo 2(22 World Health Organization. WHO. Study Group on Integration on Health Care Delivery: 10 facts about diabetes. Report Geneva [Internet]. 2013[cited 2014 Aug 18]; Available from: http://www.who.int/features/factfiles/diabetes/en/
http://www.who.int/features/factfiles/di...
). Estima-se que esse número aumentará para 353 milhões em 2030, tornando-se a 7ª principal causa de morte(33 Yach D, Stuckler D, Brownell KD. Epidemiologic and economic consequences of the global epidemics of obesity and diabetes. Nat Med [Internet]. 2006[cited 2014 Aug 18];12(1):62-6. Available from: http://www.nature.com/nm/journal/v12/n1/full/nm0106-62.html
http://www.nature.com/nm/journal/v12/n1/...
).

De 2008 a 2010, o DM e suas complicações foram responsáveis por 10,3% e 36,6% do total de hospitalizações no Sistema Único de Saúde brasileiro, com custo médio de R$ 1302 a R$ 1315 por hospitalização, respectivamente. Entre as principais complicações da doença, destacam-se as disfunções metabólicas agudas (cetoacidose e coma hipoglicêmico), microvasculares (nefropatia, retinopatia e neuropatia) e macrovasculares (doença vascular periférica, doença arterial coronariana, e acidente vascular encefálico)(44 Forbes JM, Cooper ME. Mechanisms of Diabetic Complications. Physiol Rev [Internet]. 2013[cited 2014 Aug 14];93(1)137-88. Available from: http://physrev.physiology.org/cgi/pmidlookup?view=long&pmid=23303908
http://physrev.physiology.org/cgi/pmidlo...
).

Como característico às DCNT, o tratamento do DM é complexo, pois depende diretamente da educação do paciente e de sua participação ativa no plano de cuidados para alcançar o controle glicêmico e prevenir complicações(55 Santo MBE, Souza LME, Souza ACG, Ferreira FM, Silva CNMR, Taitson PF. Adherence of patients with diabetes mellitus to the non-pharmacological and pharmacological treatment in primary health care. Enf Rev [Internet]. 2012[cited 2014 Aug 12];15(1)88-101. Available from: http://period icos.pucminas.br/index.php/enfermagemrevista/article/view/3275/3655
http://period icos.pucminas.br/index.php...
). A educação do paciente pode ser operacionalizada por meio de diferentes estratégias, com intuito de melhorar seus desfechos.

Nos últimos dez anos, foram identificadas na literatura revisões sistemáticas Cochrane sobre a efetividade e eficácia de intervenções educativas para indivíduos com diabetes em diferentes contextos: no controle da glicemia, da pressão sanguínea, do índice de massa corpórea e do colesterol(66 Duke SAS, Colagiuri S, Colagiuri R. Individual patient education for people with type 2 diabetes mellitus. Cochrane Database Syst Rev [Internet]. 2009[cited 2014 Nov 11];5268(1). Available from: http://www.ncbi.nlm.nih.gov/pubmed/19160249
http://www.ncbi.nlm.nih.gov/pubmed/19160...
-77 Attridge M, Creamer J, Ramsden M, Cannings-John R, Hawthorne K. Culturally appropriate health education for people in ethnic minority groups with type 2 diabetes mellitus. Cochrane Database Syst Rev [Internet]. 2014[cited 2014 Oct 11];6424(9). Available from: http://www.ncbi.nlm.nih.gov/pubmed/25188210
http://www.ncbi.nlm.nih.gov/pubmed/25188...
), na autoeficácia e empoderamento do paciente quanto ao controle da doença(77 Attridge M, Creamer J, Ramsden M, Cannings-John R, Hawthorne K. Culturally appropriate health education for people in ethnic minority groups with type 2 diabetes mellitus. Cochrane Database Syst Rev [Internet]. 2014[cited 2014 Oct 11];6424(9). Available from: http://www.ncbi.nlm.nih.gov/pubmed/25188210
http://www.ncbi.nlm.nih.gov/pubmed/25188...
), no conhecimento sobre DM, cessação do tabagismo, autocontrole dietético e em desfechos psicossociais(66 Duke SAS, Colagiuri S, Colagiuri R. Individual patient education for people with type 2 diabetes mellitus. Cochrane Database Syst Rev [Internet]. 2009[cited 2014 Nov 11];5268(1). Available from: http://www.ncbi.nlm.nih.gov/pubmed/19160249
http://www.ncbi.nlm.nih.gov/pubmed/19160...
) e nos cuidados com os pés e prevenção de infecções fúngicas(88 Dorresteijn JAN, Kriegsman DMW, Assendelft WJJ, Valk GD. Patient education for preventing diabetic foot ulceration. Cochrane Database Syst Rev [Internet]. 2014[cited 2014 Oct 12];1488(12). Available from: http://www.ncbi.nlm.nih.gov/pubmed/23076893
http://www.ncbi.nlm.nih.gov/pubmed/23076...
). Entretanto, apenas uma revisão sistemática avaliou a eficácia da educação na prevenção de complicações diabéticas vasculares(88 Dorresteijn JAN, Kriegsman DMW, Assendelft WJJ, Valk GD. Patient education for preventing diabetic foot ulceration. Cochrane Database Syst Rev [Internet]. 2014[cited 2014 Oct 12];1488(12). Available from: http://www.ncbi.nlm.nih.gov/pubmed/23076893
http://www.ncbi.nlm.nih.gov/pubmed/23076...
).

Nesse contexto, questiona-se: qual a efetividade e eficácia de intervenções educativas na redução das complicações diabéticas metabólicas e/ou vasculares em adultos com DM? A resposta a essa questão auxiliará os profissionais de saúde na escolha do método de ensino adequado para melhores desfechos clínicos dos pacientes. Logo, o objetivo do estudo foi identificar, na literatura, evidências da efetividade e eficácia de intervenções educativas na redução de complicações diabéticas metabólicas e/ou vasculares em adultos com DM.

MÉTODO

Aspectos éticos

Devido ao livre acesso aos estudos incluídos nesta revisão, não se tratando de documentos que requeiram sigilo ético, foi desnecessária apreciação por Comitê de Ética em Pesquisa.

Desenho do estudo

Trata-se de revisão sistemática da literatura, segundo o fluxograma do "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" (PRISMA)(99 Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ [Internet]. 2009[cited 2014 Dec 12];339:b2700. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714672/
http://www.ncbi.nlm.nih.gov/pmc/articles...
), incluindo estudos quantitativos primários experimentais ou quase experimentais. As intervenções educativas dos ensaios clínicos randomizados foram avaliadas quanto à eficácia, e as dos estudos quase experimentais segundo a efetividade.

Critérios de inclusão

Artigos científicos disponíveis na íntegra nos idiomas inglês, português e espanhol publicados de 2004 a 2014. Delimitou-se este período em virtude da publicação dos Padrões Internacionais de Educação em Diabetes pela International Diabetes Federation, no fim de 2013. O documento contém instruções sobre informações essenciais aos profissionais de saúde sobre diabetes e seu manejo, de modo que a aplicação deste conhecimento e a aquisição de habilidades melhorassem o cuidado e promovessem o alcance de desfechos positivos pelas pessoas com diabetes(1010 International Diabetes Federation. International standards for diabetes education. [Internet]. 2003[cited 2015 Jan 16]. Available from: https://www.idf.org/education/international-standards
https://www.idf.org/education/internatio...
). Realizou-se a busca nos meses de outubro e novembro de 2014, nas bases de dados primárias Literatura Latino- Americana e do Caribe em Ciências da Saúde (LILACS), Índice Bibliográfico Espanhol de Ciências da Saúde (IBECS), CUMED, Cumulative Index to Nursing and Allied Health Literature (CINAHL) e Medline e na biblioteca online Scientific Electronic Library Online (SciELO).

Protocolo do estudo

Estratégia de busca

Foi definida por meio da PICO(1111 Schardt C, Adams MB, Owens T, Keitz S, Fontel P. Utilization of the PICO framework to improve searching PubMed for clinical questions. BMC Med Inform Decis Mak [Internet]. 2007 [cited 2014 Dec 09];7(16). Available from: http://www.biomedcentral.com/1472-6947/7/16
http://www.biomedcentral.com/1472-6947/7...
), utilizando-se os Descritores em Ciências da Saúde (DECS), Medical Subject Heading (MeSH) e Títulos CINAHL com os operadores booleanos OR e AND, conforme apresentado no Quadro 1.

Quadro 1
Elementos da estratégia PICO, descritores e palavras-chave, São Paulo, Brasil, 2014

Ressalta-se que o elemento C da estratégia PICO não foi abordado, pois não era objetivo deste estudo comparar intervenções. Para garantir que o maior número possível de referências fosse encontrado, optou-se por utilizar filtros para adultos em vez de descritores ou palavras-chave, visto que frequentemente não são incluídos os grupos etários estudados como descritores. As buscas foram realizadas utilizando-se as estratégias do Quadro 2.

Quadro 2
Estratégias de busca utilizadas nas bases de dados, São Paulo, Brasil, 2004 - 2014

Seleção dos artigos

Realizada por meio da análise do título, seguida da leitura dos resumos para a identificação daqueles que seriam avaliados na íntegra, de forma independente, por duas pesquisadoras. Extraíram-se os dados da amostra final por meio de um instrumento contendo dados de identificação (autores, ano e país de publicação), desenho do estudo, tamanho da amostra/população, média de idade dos participantes, tempo médio de evolução do DM, intervenção educativa realizada, resultados e conclusões.

Avaliação da qualidade metodológica dos estudos

Realizada por duas pesquisadoras, para fins de descrição e não de exclusão da amostra. Para avaliar a qualidade dos ensaios clínicos randomizados, utilizou-se a Escala de Jadad, que consiste em três itens diretamente relacionados à redução de viés da pesquisa (randomização, cegamento e destino de todos os participantes), totalizando 5 pontos. Os estudos são classificados como de má qualidade se a pontuação for menor que 3(1212 Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials [Internet]. 1996[cited 2014 Dec 15];17:(1)1-12. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8721797
http://www.ncbi.nlm.nih.gov/pubmed/87217...
).

Para os estudos quase experimentais, realizou-se esta avaliação utilizando os critérios de Downs & Black. O questionário original contém 27 questões, totalizando escore de 32 pontos, divididas em quatro grupos: apresentação (avalia itens como clareza na descrição dos objetivos, variáveis de confusão, valores de probabilidades); validade externa (relacionada à extrapolação dos dados à população de onde a amostra foi planejada); validade interna (análise de vieses, confiabilidade das medidas de exposição e desfecho e uso de variáveis de confusão); e poder do estudo(1313 Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health [Internet]. 1998[cited 2014 Dec 28];52(6):377-84. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9764259
http://www.ncbi.nlm.nih.gov/pubmed/97642...
). Dos 27 itens originalmente propostos pelos autores, foram excluídos 6, permanecendo 21 questões, com pontuação final máxima de 24. Tais itens foram excluídos porque referiam-se a efeitos colaterais das intervenções (uma vez que não há efeitos colaterais decorrentes de intervenções educativas) ou a aspectos inerentes a ensaios clínicos randomizados ou estudos casos-controle (randomização, cegamento, comparação com grupo-controle). O ponto de corte utilizado para considerar o estudo de boa qualidade foi de 12 pontos (>50% da pontuação máxima), conforme critério estabelecido em revisão sistemática(1414 Silva AMR, Menezes AMB, Demarco FF, Vargas-Ferreira F, Peres MA. Obesity and dental caries: systematic review. Rev Saúde Pública [Internet]. 2013[cited 2014 Dec 28];47(4):799-812. Available from: http://www.scielo.br/pdf/rsp/v47n4/0034-8910-rsp-47-04-0799.pdf
http://www.scielo.br/pdf/rsp/v47n4/0034-...
).

Análise dos resultados

Os dados foram apresentados de forma descritiva e classificados de acordo com os desfechos/complicações avaliados pelos estudos incluídos nesta revisão. Devido à heterogeneidade das intervenções e das características das amostras dos estudos, não foi possível realizar metanálise.

RESULTADOS

Com base nas estratégias de busca e na seleção apresentadas na seção dos métodos, foram incluídos 24 estudos para leitura na íntegra, dos quais 11 (1515 Gershater MA, Pilhammar E, Apelqvist J, Alm-Roijer C. Patient education for the prevention of diabetic foot ulcers. Eur Diab Nursing [Internet]. 2011[cited 2014 Oct 16];8(1):102-7b. Available from: http://onlinelibrary.wiley.com/doi/10.1002/edn.189/epdf
http://onlinelibrary.wiley.com/doi/10.10...

16 Chen MY, Huang WC, Peng YS, Guo JS, Chen CP, Jong MC, et al. Effectiveness of a health promotion programme for farmers and fishermen with type-2 diabetes in Taiwan. J Adv Nurs [Internet]. 2011[cited 2014 Oct 16];67(9):2060-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21535092
http://www.ncbi.nlm.nih.gov/pubmed/21535...

17 Fujiwara Y, Kishida K, Terao M, Takahara M, Matsuhisa M, Funahashi T, et al. Beneficial effects of foot care nursing for people with diabetes mellitus: an uncontrolled before and after intervention study. J Adv Nurs [Internet]. 2011[cited 2014 Nov 15];67(9):1952-62. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21480962
http://www.ncbi.nlm.nih.gov/pubmed/21480...

18 Reda A, Hurton S, Embil JM, Smallwood S, Thomson L, Zacharias J, et al. Effect of a preventive foot care program on lower extremity complications in diabetic patients with end-stage renal disease. Foot Ankle Surg [Internet]. 2012[cited 2014 Oct 02];18(4):283-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23093125
http://www.ncbi.nlm.nih.gov/pubmed/23093...

19 Chao YH, Usher K, Buettner PG, Holmes C. Cluster randomised controlled trial: educational self-care intervention with older Taiwanese patients with Type 2 diabetes mellitus-Impact on blood glucose levels and diabetic complications. Collegian [Internet]. 2014[cited 2014 Nov 18];21(1):43-51. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24772989
http://www.ncbi.nlm.nih.gov/pubmed/24772...

20 Lincoln NB, Radford KA, Game FL, Jeffcoate WJ. Education for secondary prevention of foot ulcers in people with diabetes: a randomized controlled trial. Diabetologia [Internet]. 2008[cited 2014 Nov 18];51(11):1954-61. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18758747
http://www.ncbi.nlm.nih.gov/pubmed/18758...

21 Rachmani R, Slavacheski I, Berla M, Frommer-Shapira R, Ravid M. Treatment of high-risk patients with diabetes: motivation and teaching intervention: a randomized, prospective 8-year follow-up study. J Am Soc Nephrol [Internet]. 2005[cited 2014 Oct 18];16(1):22-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15938028
http://www.ncbi.nlm.nih.gov/pubmed/15938...

22 Fan L, Sidani S, Cooper-Brathwaite A, Metcalfe K. Feasibility, acceptability and effects of a foot self-care educational intervention on minor foot problems in adult patients with diabetes at low risk for foot ulceration: a pilot study. Can J Diabetes [Internet]. 2013[cited 2014 Nov 13];37(3):195-201. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24070843
http://www.ncbi.nlm.nih.gov/pubmed/24070...

23 Kazawa K, Moriyama M. Effects of a self-management skills acquisition program on pre-dialysis patients with diabetic nephropathy. Nephrol Nurs J [Internet]. 2013[cited 2014 Oct 03];40(2):141-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23767338
http://www.ncbi.nlm.nih.gov/pubmed/23767...

24 Viswanathan V, Madhavan S, Rajasekar S, Chamukuttan S, Ambady R. Amputation prevention initiative in South India: positive impact of foot care education. Diabetes Care [Internet]. 2005[cited 2014 Nov 15];28(5):1019-21. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15855560
http://www.ncbi.nlm.nih.gov/pubmed/15855...
-2525 Cisneros LL. Evaluation of a neuropathic ulcers prevention program for patients with diabetes. Rev Bras Fisioter [Internet]. 2010[cited 2014 Nov 09];14(1)31-7. Available from: http://www.scielo.br/pdf/rbfis/v14n1/en_06.pdf
http://www.scielo.br/pdf/rbfis/v14n1/en_...
) compuseram a amostra final. A Figura 1 apresenta o processo de seleção desses estudos.

Figura 1
Fluxograma do processo de seleção dos estudos segundo o PRISMA, São Paulo, Brasil, 2014

Características gerais e qualidade dos estudos

Os Quadros 3 e 4 apresentam as principais características, os resultados e a qualidade dos ensaios clínicos randomizados (n=5) e dos estudos quase experimentais (n=6), respectivamente.

Quadro 3
Características dos ensaios clínicos randomizados sobre a eficácia das intervenções educativas nos desfechos investigados, São Paulo, Brasil, 2004 - 2014
Quadro 4
Características dos estudos quase experimentais sobre a efetividade das intervenções educativas nos desfechos investigados, São Paulo, Brasil, 2004 - 2014

Os estudos foram realizados em diferentes continentes: asiático (n=6), americano (n=3) e europeu (n=2). A maioria das investigações (63,6%) incluiu exclusivamente pacientes com DM tipo 2(1616 Chen MY, Huang WC, Peng YS, Guo JS, Chen CP, Jong MC, et al. Effectiveness of a health promotion programme for farmers and fishermen with type-2 diabetes in Taiwan. J Adv Nurs [Internet]. 2011[cited 2014 Oct 16];67(9):2060-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21535092
http://www.ncbi.nlm.nih.gov/pubmed/21535...
,1919 Chao YH, Usher K, Buettner PG, Holmes C. Cluster randomised controlled trial: educational self-care intervention with older Taiwanese patients with Type 2 diabetes mellitus-Impact on blood glucose levels and diabetic complications. Collegian [Internet]. 2014[cited 2014 Nov 18];21(1):43-51. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24772989
http://www.ncbi.nlm.nih.gov/pubmed/24772...

20 Lincoln NB, Radford KA, Game FL, Jeffcoate WJ. Education for secondary prevention of foot ulcers in people with diabetes: a randomized controlled trial. Diabetologia [Internet]. 2008[cited 2014 Nov 18];51(11):1954-61. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18758747
http://www.ncbi.nlm.nih.gov/pubmed/18758...

21 Rachmani R, Slavacheski I, Berla M, Frommer-Shapira R, Ravid M. Treatment of high-risk patients with diabetes: motivation and teaching intervention: a randomized, prospective 8-year follow-up study. J Am Soc Nephrol [Internet]. 2005[cited 2014 Oct 18];16(1):22-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15938028
http://www.ncbi.nlm.nih.gov/pubmed/15938...

22 Fan L, Sidani S, Cooper-Brathwaite A, Metcalfe K. Feasibility, acceptability and effects of a foot self-care educational intervention on minor foot problems in adult patients with diabetes at low risk for foot ulceration: a pilot study. Can J Diabetes [Internet]. 2013[cited 2014 Nov 13];37(3):195-201. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24070843
http://www.ncbi.nlm.nih.gov/pubmed/24070...

23 Kazawa K, Moriyama M. Effects of a self-management skills acquisition program on pre-dialysis patients with diabetic nephropathy. Nephrol Nurs J [Internet]. 2013[cited 2014 Oct 03];40(2):141-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23767338
http://www.ncbi.nlm.nih.gov/pubmed/23767...
-2424 Viswanathan V, Madhavan S, Rajasekar S, Chamukuttan S, Ambady R. Amputation prevention initiative in South India: positive impact of foot care education. Diabetes Care [Internet]. 2005[cited 2014 Nov 15];28(5):1019-21. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15855560
http://www.ncbi.nlm.nih.gov/pubmed/15855...
) e três pesquisas (27,3%) consideraram também aqueles com DM tipo 1(1515 Gershater MA, Pilhammar E, Apelqvist J, Alm-Roijer C. Patient education for the prevention of diabetic foot ulcers. Eur Diab Nursing [Internet]. 2011[cited 2014 Oct 16];8(1):102-7b. Available from: http://onlinelibrary.wiley.com/doi/10.1002/edn.189/epdf
http://onlinelibrary.wiley.com/doi/10.10...
,1717 Fujiwara Y, Kishida K, Terao M, Takahara M, Matsuhisa M, Funahashi T, et al. Beneficial effects of foot care nursing for people with diabetes mellitus: an uncontrolled before and after intervention study. J Adv Nurs [Internet]. 2011[cited 2014 Nov 15];67(9):1952-62. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21480962
http://www.ncbi.nlm.nih.gov/pubmed/21480...
,2525 Cisneros LL. Evaluation of a neuropathic ulcers prevention program for patients with diabetes. Rev Bras Fisioter [Internet]. 2010[cited 2014 Nov 09];14(1)31-7. Available from: http://www.scielo.br/pdf/rbfis/v14n1/en_06.pdf
http://www.scielo.br/pdf/rbfis/v14n1/en_...
). Um estudo (9,1%) não explicitou o tipo de DM dos pacientes incluídos na amostra(1818 Reda A, Hurton S, Embil JM, Smallwood S, Thomson L, Zacharias J, et al. Effect of a preventive foot care program on lower extremity complications in diabetic patients with end-stage renal disease. Foot Ankle Surg [Internet]. 2012[cited 2014 Oct 02];18(4):283-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23093125
http://www.ncbi.nlm.nih.gov/pubmed/23093...
).

As características das amostras eram heterogêneas: o número de pacientes avaliados variou de 30(2323 Kazawa K, Moriyama M. Effects of a self-management skills acquisition program on pre-dialysis patients with diabetic nephropathy. Nephrol Nurs J [Internet]. 2013[cited 2014 Oct 03];40(2):141-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23767338
http://www.ncbi.nlm.nih.gov/pubmed/23767...
) a 4.872(2424 Viswanathan V, Madhavan S, Rajasekar S, Chamukuttan S, Ambady R. Amputation prevention initiative in South India: positive impact of foot care education. Diabetes Care [Internet]. 2005[cited 2014 Nov 15];28(5):1019-21. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15855560
http://www.ncbi.nlm.nih.gov/pubmed/15855...
), e a idade média de 55,8±13,2(2222 Fan L, Sidani S, Cooper-Brathwaite A, Metcalfe K. Feasibility, acceptability and effects of a foot self-care educational intervention on minor foot problems in adult patients with diabetes at low risk for foot ulceration: a pilot study. Can J Diabetes [Internet]. 2013[cited 2014 Nov 13];37(3):195-201. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24070843
http://www.ncbi.nlm.nih.gov/pubmed/24070...
) a 68,9±9,5(1616 Chen MY, Huang WC, Peng YS, Guo JS, Chen CP, Jong MC, et al. Effectiveness of a health promotion programme for farmers and fishermen with type-2 diabetes in Taiwan. J Adv Nurs [Internet]. 2011[cited 2014 Oct 16];67(9):2060-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21535092
http://www.ncbi.nlm.nih.gov/pubmed/21535...
) anos. O tempo médio de evolução do DM teve variação de 5,9±7,1(2222 Fan L, Sidani S, Cooper-Brathwaite A, Metcalfe K. Feasibility, acceptability and effects of a foot self-care educational intervention on minor foot problems in adult patients with diabetes at low risk for foot ulceration: a pilot study. Can J Diabetes [Internet]. 2013[cited 2014 Nov 13];37(3):195-201. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24070843
http://www.ncbi.nlm.nih.gov/pubmed/24070...
) a 22±11,4 anos(1717 Fujiwara Y, Kishida K, Terao M, Takahara M, Matsuhisa M, Funahashi T, et al. Beneficial effects of foot care nursing for people with diabetes mellitus: an uncontrolled before and after intervention study. J Adv Nurs [Internet]. 2011[cited 2014 Nov 15];67(9):1952-62. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21480962
http://www.ncbi.nlm.nih.gov/pubmed/21480...
); porém, três estudos não apresentaram essa informação(1515 Gershater MA, Pilhammar E, Apelqvist J, Alm-Roijer C. Patient education for the prevention of diabetic foot ulcers. Eur Diab Nursing [Internet]. 2011[cited 2014 Oct 16];8(1):102-7b. Available from: http://onlinelibrary.wiley.com/doi/10.1002/edn.189/epdf
http://onlinelibrary.wiley.com/doi/10.10...
,1818 Reda A, Hurton S, Embil JM, Smallwood S, Thomson L, Zacharias J, et al. Effect of a preventive foot care program on lower extremity complications in diabetic patients with end-stage renal disease. Foot Ankle Surg [Internet]. 2012[cited 2014 Oct 02];18(4):283-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23093125
http://www.ncbi.nlm.nih.gov/pubmed/23093...
,2020 Lincoln NB, Radford KA, Game FL, Jeffcoate WJ. Education for secondary prevention of foot ulcers in people with diabetes: a randomized controlled trial. Diabetologia [Internet]. 2008[cited 2014 Nov 18];51(11):1954-61. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18758747
http://www.ncbi.nlm.nih.gov/pubmed/18758...
). O tempo de acompanhamento dos pacientes após a intervenção variou de 3 meses(2222 Fan L, Sidani S, Cooper-Brathwaite A, Metcalfe K. Feasibility, acceptability and effects of a foot self-care educational intervention on minor foot problems in adult patients with diabetes at low risk for foot ulceration: a pilot study. Can J Diabetes [Internet]. 2013[cited 2014 Nov 13];37(3):195-201. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24070843
http://www.ncbi.nlm.nih.gov/pubmed/24070...
) a 7,7 anos(2121 Rachmani R, Slavacheski I, Berla M, Frommer-Shapira R, Ravid M. Treatment of high-risk patients with diabetes: motivation and teaching intervention: a randomized, prospective 8-year follow-up study. J Am Soc Nephrol [Internet]. 2005[cited 2014 Oct 18];16(1):22-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15938028
http://www.ncbi.nlm.nih.gov/pubmed/15938...
).

Três dos cinco ensaios clínicos randomizados(1515 Gershater MA, Pilhammar E, Apelqvist J, Alm-Roijer C. Patient education for the prevention of diabetic foot ulcers. Eur Diab Nursing [Internet]. 2011[cited 2014 Oct 16];8(1):102-7b. Available from: http://onlinelibrary.wiley.com/doi/10.1002/edn.189/epdf
http://onlinelibrary.wiley.com/doi/10.10...
,2020 Lincoln NB, Radford KA, Game FL, Jeffcoate WJ. Education for secondary prevention of foot ulcers in people with diabetes: a randomized controlled trial. Diabetologia [Internet]. 2008[cited 2014 Nov 18];51(11):1954-61. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18758747
http://www.ncbi.nlm.nih.gov/pubmed/18758...
-2121 Rachmani R, Slavacheski I, Berla M, Frommer-Shapira R, Ravid M. Treatment of high-risk patients with diabetes: motivation and teaching intervention: a randomized, prospective 8-year follow-up study. J Am Soc Nephrol [Internet]. 2005[cited 2014 Oct 18];16(1):22-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15938028
http://www.ncbi.nlm.nih.gov/pubmed/15938...
) foram considerados de qualidade e cinco dos seis estudos quase experimentais(1616 Chen MY, Huang WC, Peng YS, Guo JS, Chen CP, Jong MC, et al. Effectiveness of a health promotion programme for farmers and fishermen with type-2 diabetes in Taiwan. J Adv Nurs [Internet]. 2011[cited 2014 Oct 16];67(9):2060-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21535092
http://www.ncbi.nlm.nih.gov/pubmed/21535...

17 Fujiwara Y, Kishida K, Terao M, Takahara M, Matsuhisa M, Funahashi T, et al. Beneficial effects of foot care nursing for people with diabetes mellitus: an uncontrolled before and after intervention study. J Adv Nurs [Internet]. 2011[cited 2014 Nov 15];67(9):1952-62. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21480962
http://www.ncbi.nlm.nih.gov/pubmed/21480...
-1818 Reda A, Hurton S, Embil JM, Smallwood S, Thomson L, Zacharias J, et al. Effect of a preventive foot care program on lower extremity complications in diabetic patients with end-stage renal disease. Foot Ankle Surg [Internet]. 2012[cited 2014 Oct 02];18(4):283-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23093125
http://www.ncbi.nlm.nih.gov/pubmed/23093...
,2222 Fan L, Sidani S, Cooper-Brathwaite A, Metcalfe K. Feasibility, acceptability and effects of a foot self-care educational intervention on minor foot problems in adult patients with diabetes at low risk for foot ulceration: a pilot study. Can J Diabetes [Internet]. 2013[cited 2014 Nov 13];37(3):195-201. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24070843
http://www.ncbi.nlm.nih.gov/pubmed/24070...
-2323 Kazawa K, Moriyama M. Effects of a self-management skills acquisition program on pre-dialysis patients with diabetic nephropathy. Nephrol Nurs J [Internet]. 2013[cited 2014 Oct 03];40(2):141-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23767338
http://www.ncbi.nlm.nih.gov/pubmed/23767...
) classificados como de boa qualidade.

Profissionais que implementaram as intervenções

Um estudo não relatou quais profissionais implementaram a intervenção educativa(2424 Viswanathan V, Madhavan S, Rajasekar S, Chamukuttan S, Ambady R. Amputation prevention initiative in South India: positive impact of foot care education. Diabetes Care [Internet]. 2005[cited 2014 Nov 15];28(5):1019-21. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15855560
http://www.ncbi.nlm.nih.gov/pubmed/15855...
). A participação de enfermeiros nas orientações foi expressiva, pois estavam presentes em 80,0% das investigações(1515 Gershater MA, Pilhammar E, Apelqvist J, Alm-Roijer C. Patient education for the prevention of diabetic foot ulcers. Eur Diab Nursing [Internet]. 2011[cited 2014 Oct 16];8(1):102-7b. Available from: http://onlinelibrary.wiley.com/doi/10.1002/edn.189/epdf
http://onlinelibrary.wiley.com/doi/10.10...

16 Chen MY, Huang WC, Peng YS, Guo JS, Chen CP, Jong MC, et al. Effectiveness of a health promotion programme for farmers and fishermen with type-2 diabetes in Taiwan. J Adv Nurs [Internet]. 2011[cited 2014 Oct 16];67(9):2060-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21535092
http://www.ncbi.nlm.nih.gov/pubmed/21535...

17 Fujiwara Y, Kishida K, Terao M, Takahara M, Matsuhisa M, Funahashi T, et al. Beneficial effects of foot care nursing for people with diabetes mellitus: an uncontrolled before and after intervention study. J Adv Nurs [Internet]. 2011[cited 2014 Nov 15];67(9):1952-62. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21480962
http://www.ncbi.nlm.nih.gov/pubmed/21480...

18 Reda A, Hurton S, Embil JM, Smallwood S, Thomson L, Zacharias J, et al. Effect of a preventive foot care program on lower extremity complications in diabetic patients with end-stage renal disease. Foot Ankle Surg [Internet]. 2012[cited 2014 Oct 02];18(4):283-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23093125
http://www.ncbi.nlm.nih.gov/pubmed/23093...

19 Chao YH, Usher K, Buettner PG, Holmes C. Cluster randomised controlled trial: educational self-care intervention with older Taiwanese patients with Type 2 diabetes mellitus-Impact on blood glucose levels and diabetic complications. Collegian [Internet]. 2014[cited 2014 Nov 18];21(1):43-51. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24772989
http://www.ncbi.nlm.nih.gov/pubmed/24772...
-2020 Lincoln NB, Radford KA, Game FL, Jeffcoate WJ. Education for secondary prevention of foot ulcers in people with diabetes: a randomized controlled trial. Diabetologia [Internet]. 2008[cited 2014 Nov 18];51(11):1954-61. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18758747
http://www.ncbi.nlm.nih.gov/pubmed/18758...
,2222 Fan L, Sidani S, Cooper-Brathwaite A, Metcalfe K. Feasibility, acceptability and effects of a foot self-care educational intervention on minor foot problems in adult patients with diabetes at low risk for foot ulceration: a pilot study. Can J Diabetes [Internet]. 2013[cited 2014 Nov 13];37(3):195-201. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24070843
http://www.ncbi.nlm.nih.gov/pubmed/24070...
-2323 Kazawa K, Moriyama M. Effects of a self-management skills acquisition program on pre-dialysis patients with diabetic nephropathy. Nephrol Nurs J [Internet]. 2013[cited 2014 Oct 03];40(2):141-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23767338
http://www.ncbi.nlm.nih.gov/pubmed/23767...
). Alguns estudos mostraram o trabalho multidisciplinar por meio da atuação de diferentes categorias profissionais nas intervenções: médicos e enfermeiros(1616 Chen MY, Huang WC, Peng YS, Guo JS, Chen CP, Jong MC, et al. Effectiveness of a health promotion programme for farmers and fishermen with type-2 diabetes in Taiwan. J Adv Nurs [Internet]. 2011[cited 2014 Oct 16];67(9):2060-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21535092
http://www.ncbi.nlm.nih.gov/pubmed/21535...
,1919 Chao YH, Usher K, Buettner PG, Holmes C. Cluster randomised controlled trial: educational self-care intervention with older Taiwanese patients with Type 2 diabetes mellitus-Impact on blood glucose levels and diabetic complications. Collegian [Internet]. 2014[cited 2014 Nov 18];21(1):43-51. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24772989
http://www.ncbi.nlm.nih.gov/pubmed/24772...
), médicos e nutricionistas(1919 Chao YH, Usher K, Buettner PG, Holmes C. Cluster randomised controlled trial: educational self-care intervention with older Taiwanese patients with Type 2 diabetes mellitus-Impact on blood glucose levels and diabetic complications. Collegian [Internet]. 2014[cited 2014 Nov 18];21(1):43-51. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24772989
http://www.ncbi.nlm.nih.gov/pubmed/24772...
) e terapeutas ocupacionais e enfermeiros(2020 Lincoln NB, Radford KA, Game FL, Jeffcoate WJ. Education for secondary prevention of foot ulcers in people with diabetes: a randomized controlled trial. Diabetologia [Internet]. 2008[cited 2014 Nov 18];51(11):1954-61. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18758747
http://www.ncbi.nlm.nih.gov/pubmed/18758...
). Duas pesquisas trouxeram a atuação exclusiva de médicos(2121 Rachmani R, Slavacheski I, Berla M, Frommer-Shapira R, Ravid M. Treatment of high-risk patients with diabetes: motivation and teaching intervention: a randomized, prospective 8-year follow-up study. J Am Soc Nephrol [Internet]. 2005[cited 2014 Oct 18];16(1):22-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15938028
http://www.ncbi.nlm.nih.gov/pubmed/15938...
) e fisioterapeutas(2525 Cisneros LL. Evaluation of a neuropathic ulcers prevention program for patients with diabetes. Rev Bras Fisioter [Internet]. 2010[cited 2014 Nov 09];14(1)31-7. Available from: http://www.scielo.br/pdf/rbfis/v14n1/en_06.pdf
http://www.scielo.br/pdf/rbfis/v14n1/en_...
) nas intervenções educativas aos diabéticos.

Efetividade e eficácia das intervenções na redução de complicações diabéticas

Dos 11 estudos identificados, dois ensaios clínicos mostraram eficácia da intervenção na redução de complicações cardiovasculares(2121 Rachmani R, Slavacheski I, Berla M, Frommer-Shapira R, Ravid M. Treatment of high-risk patients with diabetes: motivation and teaching intervention: a randomized, prospective 8-year follow-up study. J Am Soc Nephrol [Internet]. 2005[cited 2014 Oct 18];16(1):22-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15938028
http://www.ncbi.nlm.nih.gov/pubmed/15938...
), da catarata ou retinopatia e nefropatia(1919 Chao YH, Usher K, Buettner PG, Holmes C. Cluster randomised controlled trial: educational self-care intervention with older Taiwanese patients with Type 2 diabetes mellitus-Impact on blood glucose levels and diabetic complications. Collegian [Internet]. 2014[cited 2014 Nov 18];21(1):43-51. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24772989
http://www.ncbi.nlm.nih.gov/pubmed/24772...
,2121 Rachmani R, Slavacheski I, Berla M, Frommer-Shapira R, Ravid M. Treatment of high-risk patients with diabetes: motivation and teaching intervention: a randomized, prospective 8-year follow-up study. J Am Soc Nephrol [Internet]. 2005[cited 2014 Oct 18];16(1):22-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15938028
http://www.ncbi.nlm.nih.gov/pubmed/15938...
) (Quadro 3). Todas as pesquisas quase experimentais mostraram efetividade das intervenções: houve redução das úlceras nos pés(1717 Fujiwara Y, Kishida K, Terao M, Takahara M, Matsuhisa M, Funahashi T, et al. Beneficial effects of foot care nursing for people with diabetes mellitus: an uncontrolled before and after intervention study. J Adv Nurs [Internet]. 2011[cited 2014 Nov 15];67(9):1952-62. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21480962
http://www.ncbi.nlm.nih.gov/pubmed/21480...
,2222 Fan L, Sidani S, Cooper-Brathwaite A, Metcalfe K. Feasibility, acceptability and effects of a foot self-care educational intervention on minor foot problems in adult patients with diabetes at low risk for foot ulceration: a pilot study. Can J Diabetes [Internet]. 2013[cited 2014 Nov 13];37(3):195-201. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24070843
http://www.ncbi.nlm.nih.gov/pubmed/24070...
,2424 Viswanathan V, Madhavan S, Rajasekar S, Chamukuttan S, Ambady R. Amputation prevention initiative in South India: positive impact of foot care education. Diabetes Care [Internet]. 2005[cited 2014 Nov 15];28(5):1019-21. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15855560
http://www.ncbi.nlm.nih.gov/pubmed/15855...
), da vasculopatia periférica(1616 Chen MY, Huang WC, Peng YS, Guo JS, Chen CP, Jong MC, et al. Effectiveness of a health promotion programme for farmers and fishermen with type-2 diabetes in Taiwan. J Adv Nurs [Internet]. 2011[cited 2014 Oct 16];67(9):2060-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21535092
http://www.ncbi.nlm.nih.gov/pubmed/21535...
) e da neuropatia periférica(1818 Reda A, Hurton S, Embil JM, Smallwood S, Thomson L, Zacharias J, et al. Effect of a preventive foot care program on lower extremity complications in diabetic patients with end-stage renal disease. Foot Ankle Surg [Internet]. 2012[cited 2014 Oct 02];18(4):283-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23093125
http://www.ncbi.nlm.nih.gov/pubmed/23093...
), além da manutenção da função renal(2323 Kazawa K, Moriyama M. Effects of a self-management skills acquisition program on pre-dialysis patients with diabetic nephropathy. Nephrol Nurs J [Internet]. 2013[cited 2014 Oct 03];40(2):141-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23767338
http://www.ncbi.nlm.nih.gov/pubmed/23767...
) (Quadro 4).

Quanto às intervenções com impacto positivo na redução das complicações, a maioria foi implementada exclusivamente por enfermeiros(1515 Gershater MA, Pilhammar E, Apelqvist J, Alm-Roijer C. Patient education for the prevention of diabetic foot ulcers. Eur Diab Nursing [Internet]. 2011[cited 2014 Oct 16];8(1):102-7b. Available from: http://onlinelibrary.wiley.com/doi/10.1002/edn.189/epdf
http://onlinelibrary.wiley.com/doi/10.10...
,1717 Fujiwara Y, Kishida K, Terao M, Takahara M, Matsuhisa M, Funahashi T, et al. Beneficial effects of foot care nursing for people with diabetes mellitus: an uncontrolled before and after intervention study. J Adv Nurs [Internet]. 2011[cited 2014 Nov 15];67(9):1952-62. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21480962
http://www.ncbi.nlm.nih.gov/pubmed/21480...
-1818 Reda A, Hurton S, Embil JM, Smallwood S, Thomson L, Zacharias J, et al. Effect of a preventive foot care program on lower extremity complications in diabetic patients with end-stage renal disease. Foot Ankle Surg [Internet]. 2012[cited 2014 Oct 02];18(4):283-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23093125
http://www.ncbi.nlm.nih.gov/pubmed/23093...
,2222 Fan L, Sidani S, Cooper-Brathwaite A, Metcalfe K. Feasibility, acceptability and effects of a foot self-care educational intervention on minor foot problems in adult patients with diabetes at low risk for foot ulceration: a pilot study. Can J Diabetes [Internet]. 2013[cited 2014 Nov 13];37(3):195-201. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24070843
http://www.ncbi.nlm.nih.gov/pubmed/24070...
-2323 Kazawa K, Moriyama M. Effects of a self-management skills acquisition program on pre-dialysis patients with diabetic nephropathy. Nephrol Nurs J [Internet]. 2013[cited 2014 Oct 03];40(2):141-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23767338
http://www.ncbi.nlm.nih.gov/pubmed/23767...
) ou em parceria com outros profissionais(1616 Chen MY, Huang WC, Peng YS, Guo JS, Chen CP, Jong MC, et al. Effectiveness of a health promotion programme for farmers and fishermen with type-2 diabetes in Taiwan. J Adv Nurs [Internet]. 2011[cited 2014 Oct 16];67(9):2060-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21535092
http://www.ncbi.nlm.nih.gov/pubmed/21535...
,1919 Chao YH, Usher K, Buettner PG, Holmes C. Cluster randomised controlled trial: educational self-care intervention with older Taiwanese patients with Type 2 diabetes mellitus-Impact on blood glucose levels and diabetic complications. Collegian [Internet]. 2014[cited 2014 Nov 18];21(1):43-51. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24772989
http://www.ncbi.nlm.nih.gov/pubmed/24772...
-2020 Lincoln NB, Radford KA, Game FL, Jeffcoate WJ. Education for secondary prevention of foot ulcers in people with diabetes: a randomized controlled trial. Diabetologia [Internet]. 2008[cited 2014 Nov 18];51(11):1954-61. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18758747
http://www.ncbi.nlm.nih.gov/pubmed/18758...
). Um estudo teve a participação exclusiva de médicos(2121 Rachmani R, Slavacheski I, Berla M, Frommer-Shapira R, Ravid M. Treatment of high-risk patients with diabetes: motivation and teaching intervention: a randomized, prospective 8-year follow-up study. J Am Soc Nephrol [Internet]. 2005[cited 2014 Oct 18];16(1):22-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15938028
http://www.ncbi.nlm.nih.gov/pubmed/15938...
). Não houve similaridade entre a média de idade ou tempo de evolução do DM dos pacientes nos diferentes estudos. A maioria das intervenções efetivas ou eficazes era composta por sessões individuais(1818 Reda A, Hurton S, Embil JM, Smallwood S, Thomson L, Zacharias J, et al. Effect of a preventive foot care program on lower extremity complications in diabetic patients with end-stage renal disease. Foot Ankle Surg [Internet]. 2012[cited 2014 Oct 02];18(4):283-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23093125
http://www.ncbi.nlm.nih.gov/pubmed/23093...

19 Chao YH, Usher K, Buettner PG, Holmes C. Cluster randomised controlled trial: educational self-care intervention with older Taiwanese patients with Type 2 diabetes mellitus-Impact on blood glucose levels and diabetic complications. Collegian [Internet]. 2014[cited 2014 Nov 18];21(1):43-51. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24772989
http://www.ncbi.nlm.nih.gov/pubmed/24772...

20 Lincoln NB, Radford KA, Game FL, Jeffcoate WJ. Education for secondary prevention of foot ulcers in people with diabetes: a randomized controlled trial. Diabetologia [Internet]. 2008[cited 2014 Nov 18];51(11):1954-61. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18758747
http://www.ncbi.nlm.nih.gov/pubmed/18758...

21 Rachmani R, Slavacheski I, Berla M, Frommer-Shapira R, Ravid M. Treatment of high-risk patients with diabetes: motivation and teaching intervention: a randomized, prospective 8-year follow-up study. J Am Soc Nephrol [Internet]. 2005[cited 2014 Oct 18];16(1):22-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15938028
http://www.ncbi.nlm.nih.gov/pubmed/15938...

22 Fan L, Sidani S, Cooper-Brathwaite A, Metcalfe K. Feasibility, acceptability and effects of a foot self-care educational intervention on minor foot problems in adult patients with diabetes at low risk for foot ulceration: a pilot study. Can J Diabetes [Internet]. 2013[cited 2014 Nov 13];37(3):195-201. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24070843
http://www.ncbi.nlm.nih.gov/pubmed/24070...
-2323 Kazawa K, Moriyama M. Effects of a self-management skills acquisition program on pre-dialysis patients with diabetic nephropathy. Nephrol Nurs J [Internet]. 2013[cited 2014 Oct 03];40(2):141-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23767338
http://www.ncbi.nlm.nih.gov/pubmed/23767...
). Um estudo envolveu o grupo da comunidade nas sessões(1616 Chen MY, Huang WC, Peng YS, Guo JS, Chen CP, Jong MC, et al. Effectiveness of a health promotion programme for farmers and fishermen with type-2 diabetes in Taiwan. J Adv Nurs [Internet]. 2011[cited 2014 Oct 16];67(9):2060-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21535092
http://www.ncbi.nlm.nih.gov/pubmed/21535...
) e outro, a família do paciente(2424 Viswanathan V, Madhavan S, Rajasekar S, Chamukuttan S, Ambady R. Amputation prevention initiative in South India: positive impact of foot care education. Diabetes Care [Internet]. 2005[cited 2014 Nov 15];28(5):1019-21. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15855560
http://www.ncbi.nlm.nih.gov/pubmed/15855...
). Duas investigações incluíram intervenções customizadas com intervalo entre as sessões educativas de acordo com o perfil de risco dos pacientes ou presença de neuropatia diabética, doença arterial periférica e/ou deformidade, história de úlcera ou amputação do pé(1717 Fujiwara Y, Kishida K, Terao M, Takahara M, Matsuhisa M, Funahashi T, et al. Beneficial effects of foot care nursing for people with diabetes mellitus: an uncontrolled before and after intervention study. J Adv Nurs [Internet]. 2011[cited 2014 Nov 15];67(9):1952-62. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21480962
http://www.ncbi.nlm.nih.gov/pubmed/21480...
) e uso de órteses(2424 Viswanathan V, Madhavan S, Rajasekar S, Chamukuttan S, Ambady R. Amputation prevention initiative in South India: positive impact of foot care education. Diabetes Care [Internet]. 2005[cited 2014 Nov 15];28(5):1019-21. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15855560
http://www.ncbi.nlm.nih.gov/pubmed/15855...
). Uma envolvia contato telefônico e treinamento prático como medidas associadas(2222 Fan L, Sidani S, Cooper-Brathwaite A, Metcalfe K. Feasibility, acceptability and effects of a foot self-care educational intervention on minor foot problems in adult patients with diabetes at low risk for foot ulceration: a pilot study. Can J Diabetes [Internet]. 2013[cited 2014 Nov 13];37(3):195-201. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24070843
http://www.ncbi.nlm.nih.gov/pubmed/24070...
) e duas implementavam apenas contato telefônico como medida adjuvante(1616 Chen MY, Huang WC, Peng YS, Guo JS, Chen CP, Jong MC, et al. Effectiveness of a health promotion programme for farmers and fishermen with type-2 diabetes in Taiwan. J Adv Nurs [Internet]. 2011[cited 2014 Oct 16];67(9):2060-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21535092
http://www.ncbi.nlm.nih.gov/pubmed/21535...
,2323 Kazawa K, Moriyama M. Effects of a self-management skills acquisition program on pre-dialysis patients with diabetic nephropathy. Nephrol Nurs J [Internet]. 2013[cited 2014 Oct 03];40(2):141-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23767338
http://www.ncbi.nlm.nih.gov/pubmed/23767...
).

DISCUSSÃO

Este estudo buscou evidências quanto ao impacto de intervenções educativas na redução de complicações vasculares e metabólicas do DM. Porém, apenas estudos que analisaram complicações vasculares foram encontrados, o que pode estar associado à importância destas complicações como principais causas de morbimortalidade em pacientes com DM(77 Attridge M, Creamer J, Ramsden M, Cannings-John R, Hawthorne K. Culturally appropriate health education for people in ethnic minority groups with type 2 diabetes mellitus. Cochrane Database Syst Rev [Internet]. 2014[cited 2014 Oct 11];6424(9). Available from: http://www.ncbi.nlm.nih.gov/pubmed/25188210
http://www.ncbi.nlm.nih.gov/pubmed/25188...
).

A adesão à modificação comportamental e de estilo de vida promovida pela educação do DM é influenciada pelo tempo da doença. Estudo mostrou que indivíduos com DM há menos de um ano apresentaram maior adesão a hábitos dietéticos adequados e à atividade física e menores níveis de hemoglobina glicada após 3 anos de acompanhamento(2626 Ko SH, Park SA, Cho JH, Ko SH, Shin KM, Lee SH, et al. Influence of the Duration of Diabetes on the Outcome of a Diabetes Self-Management Education Program. Diabetes Metab J [Internet]. 2012[cited 2014 Nov 17];36(3):222-9.Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3380126/
http://www.ncbi.nlm.nih.gov/pmc/articles...
). Por outro lado, pacientes com DM 2 diagnosticados há mais de 20 anos teriam um pior controle metabólico em razão da baixa adesão ao regime terapêutico, evolução da doença com disfunção progressiva das células-beta e ausência de ajustes dos medicamentos quando comparados àqueles com tempo de diagnóstico inferior a cinco anos(2727 Santos MJ, Monteiro M, Pereira P, Freitas M, Marques O. Therapeutic pattern in a population of type 2 diabetics: relationship with disease duration and type of health care. Rev Port Endocrinol Diabetes Metab [Internet]. 2014[cited 2014 Nov 04];9(1):15-20. Available from: http://www.sciencedir ect.com/science/article/pii/S1646343914000042
http://www.sciencedir ect.com/science/ar...
). Assim, não é possível saber se a evolução do DM pode ter influenciado os resultados negativos obtidos pelos estudos que não descreveram o tempo da doença(1515 Gershater MA, Pilhammar E, Apelqvist J, Alm-Roijer C. Patient education for the prevention of diabetic foot ulcers. Eur Diab Nursing [Internet]. 2011[cited 2014 Oct 16];8(1):102-7b. Available from: http://onlinelibrary.wiley.com/doi/10.1002/edn.189/epdf
http://onlinelibrary.wiley.com/doi/10.10...
,1818 Reda A, Hurton S, Embil JM, Smallwood S, Thomson L, Zacharias J, et al. Effect of a preventive foot care program on lower extremity complications in diabetic patients with end-stage renal disease. Foot Ankle Surg [Internet]. 2012[cited 2014 Oct 02];18(4):283-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23093125
http://www.ncbi.nlm.nih.gov/pubmed/23093...
,2020 Lincoln NB, Radford KA, Game FL, Jeffcoate WJ. Education for secondary prevention of foot ulcers in people with diabetes: a randomized controlled trial. Diabetologia [Internet]. 2008[cited 2014 Nov 18];51(11):1954-61. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18758747
http://www.ncbi.nlm.nih.gov/pubmed/18758...
).

Investigações apontam que o controle inadequado da glicemia é um fator associado à presença de úlceras nos pés(2828 Martin IS, Beraldo AA, Passeri SM, Freitas MCF, Pace AN. Root causes for the development of foot ulcers of people with diabetes mellitus. Acta Paul Enferm [Internet]. 2012[cited 2014 Dec 29];25(2):218-24. Available from: www.scielo.br/pdf/ape/v25n2/en_a10v25n2.pdf
www.scielo.br/pdf/ape/v25n2/en_a10v25n2....
) e à amputação entre indivíduos com pé diabético(2929 Santos ICRV, Sobreira CMM, Nunes ENS, Morais MCA. [The prevalence and factors associated with diabetic foot amputations]. Ciênc Saúde Colet [Internet]. 2013[cited 2014 Dec 29];18(10):3007-14. Available from: http://www.scielosp.org/pdf/csc/v18n10/v18n10a25.pdf Portuguese
http://www.scielosp.org/pdf/csc/v18n10/v...
). No entanto, é importante a análise da influência das intervenções educativas em desfechos associados às complicações do DM, além dos níveis séricos pontuais da glicemia ou da hemoglobina glicada. Assim, reforça-se a importância desta revisão, cujos resultados serão discutidos de acordo com as complicações micro e macrovasculares do DM.

Complicações microvasculares: retinopatia(1919 Chao YH, Usher K, Buettner PG, Holmes C. Cluster randomised controlled trial: educational self-care intervention with older Taiwanese patients with Type 2 diabetes mellitus-Impact on blood glucose levels and diabetic complications. Collegian [Internet]. 2014[cited 2014 Nov 18];21(1):43-51. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24772989
http://www.ncbi.nlm.nih.gov/pubmed/24772...
,2121 Rachmani R, Slavacheski I, Berla M, Frommer-Shapira R, Ravid M. Treatment of high-risk patients with diabetes: motivation and teaching intervention: a randomized, prospective 8-year follow-up study. J Am Soc Nephrol [Internet]. 2005[cited 2014 Oct 18];16(1):22-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15938028
http://www.ncbi.nlm.nih.gov/pubmed/15938...
), neuropatia periférica(1616 Chen MY, Huang WC, Peng YS, Guo JS, Chen CP, Jong MC, et al. Effectiveness of a health promotion programme for farmers and fishermen with type-2 diabetes in Taiwan. J Adv Nurs [Internet]. 2011[cited 2014 Oct 16];67(9):2060-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21535092
http://www.ncbi.nlm.nih.gov/pubmed/21535...
,1818 Reda A, Hurton S, Embil JM, Smallwood S, Thomson L, Zacharias J, et al. Effect of a preventive foot care program on lower extremity complications in diabetic patients with end-stage renal disease. Foot Ankle Surg [Internet]. 2012[cited 2014 Oct 02];18(4):283-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23093125
http://www.ncbi.nlm.nih.gov/pubmed/23093...
,2525 Cisneros LL. Evaluation of a neuropathic ulcers prevention program for patients with diabetes. Rev Bras Fisioter [Internet]. 2010[cited 2014 Nov 09];14(1)31-7. Available from: http://www.scielo.br/pdf/rbfis/v14n1/en_06.pdf
http://www.scielo.br/pdf/rbfis/v14n1/en_...
) e nefropatia(1919 Chao YH, Usher K, Buettner PG, Holmes C. Cluster randomised controlled trial: educational self-care intervention with older Taiwanese patients with Type 2 diabetes mellitus-Impact on blood glucose levels and diabetic complications. Collegian [Internet]. 2014[cited 2014 Nov 18];21(1):43-51. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24772989
http://www.ncbi.nlm.nih.gov/pubmed/24772...
,2121 Rachmani R, Slavacheski I, Berla M, Frommer-Shapira R, Ravid M. Treatment of high-risk patients with diabetes: motivation and teaching intervention: a randomized, prospective 8-year follow-up study. J Am Soc Nephrol [Internet]. 2005[cited 2014 Oct 18];16(1):22-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15938028
http://www.ncbi.nlm.nih.gov/pubmed/15938...
,2323 Kazawa K, Moriyama M. Effects of a self-management skills acquisition program on pre-dialysis patients with diabetic nephropathy. Nephrol Nurs J [Internet]. 2013[cited 2014 Oct 03];40(2):141-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23767338
http://www.ncbi.nlm.nih.gov/pubmed/23767...
)

No mundo, as complicações microvasculares do DM são encontradas em alta prevalência. Aproximadamente 93 milhões de pessoas têm retinopatia diabética e essa é, potencialmente, a principal causa de prejuízo visual e cegueira(3030 Yau JW, Rogers SL, Kawasaki R, Lamoureux EL, Kowalski JW, Bek T, et al. Global prevalence and major risk factors of diabetic retinopathy. Diabetes Care [Internet]. 2012[cited 2014 Dec 30];35(3):556-64. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22301125
http://www.ncbi.nlm.nih.gov/pubmed/22301...
). Além disso, verificou-se, entre indivíduos com retinopatia diabética, a coexistência de nefropatia, neuropatia e doença vascular periférica(3131 Venkatesh P, Tibrewal S, Bhowmik D, Tripathi M, Ramakrishnan S, Vashist N. Prevalence of systemic co-morbidities in patients with various grades of diabetic retinopathy. Indian J Med Res [Internet]. 2014[cited 2014 Dec 29];140(1):77-83. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25222781
http://www.ncbi.nlm.nih.gov/pubmed/25222...
).

A neuropatia periférica diabética, caracterizada por dor, parestesia e perda sensorial, afeta até 50% dos pacientes com DM tanto do tipo 1 quanto do tipo 2(3232 Tesfaye S. Recent advances in the management of diabetic distal symmetrical polyneuropathy. J Diabetes Investig [Internet]. 2011[cited 2014 Dec 29];2(1):33-42. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4008012/
http://www.ncbi.nlm.nih.gov/pmc/articles...
). A nefropatia diabética atinge cerca de um terço das pessoas com DM no mundo, configurando-se a principal causa de insuficiência renal terminal associada a doenças cardiovasculares e aumento da mortalidade dos pacientes(3333 Reutens AT, Atkins RC. Epidemiology of Diabetic Nephropathy: diabetes and the kidney. Contrib Nephrol [Internet]. 2011[cited 2014 Dec 30];170(1):1-7. Available from: http://www.karger.com/Article/Abstract/324934
http://www.karger.com/Article/Abstract/3...
).

Para a redução dessas complicações, a maioria dos estudos desta revisão(1818 Reda A, Hurton S, Embil JM, Smallwood S, Thomson L, Zacharias J, et al. Effect of a preventive foot care program on lower extremity complications in diabetic patients with end-stage renal disease. Foot Ankle Surg [Internet]. 2012[cited 2014 Oct 02];18(4):283-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23093125
http://www.ncbi.nlm.nih.gov/pubmed/23093...

19 Chao YH, Usher K, Buettner PG, Holmes C. Cluster randomised controlled trial: educational self-care intervention with older Taiwanese patients with Type 2 diabetes mellitus-Impact on blood glucose levels and diabetic complications. Collegian [Internet]. 2014[cited 2014 Nov 18];21(1):43-51. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24772989
http://www.ncbi.nlm.nih.gov/pubmed/24772...

20 Lincoln NB, Radford KA, Game FL, Jeffcoate WJ. Education for secondary prevention of foot ulcers in people with diabetes: a randomized controlled trial. Diabetologia [Internet]. 2008[cited 2014 Nov 18];51(11):1954-61. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18758747
http://www.ncbi.nlm.nih.gov/pubmed/18758...

21 Rachmani R, Slavacheski I, Berla M, Frommer-Shapira R, Ravid M. Treatment of high-risk patients with diabetes: motivation and teaching intervention: a randomized, prospective 8-year follow-up study. J Am Soc Nephrol [Internet]. 2005[cited 2014 Oct 18];16(1):22-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15938028
http://www.ncbi.nlm.nih.gov/pubmed/15938...

22 Fan L, Sidani S, Cooper-Brathwaite A, Metcalfe K. Feasibility, acceptability and effects of a foot self-care educational intervention on minor foot problems in adult patients with diabetes at low risk for foot ulceration: a pilot study. Can J Diabetes [Internet]. 2013[cited 2014 Nov 13];37(3):195-201. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24070843
http://www.ncbi.nlm.nih.gov/pubmed/24070...
-2323 Kazawa K, Moriyama M. Effects of a self-management skills acquisition program on pre-dialysis patients with diabetic nephropathy. Nephrol Nurs J [Internet]. 2013[cited 2014 Oct 03];40(2):141-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23767338
http://www.ncbi.nlm.nih.gov/pubmed/23767...
) utilizou como estratégia as sessões individuais durante as intervenções educativas. As sessões e avaliações individuais estreitam o vínculo do paciente com o profissional, que passa a conhecer o indivíduo e as suas práticas de gerenciamento do cuidado. Assim, em parceria, é possível desenvolver a autonomia do cuidado(3434 Torres HC, Pereira FRL, Alexandre LR. Evaluation of the educational practices in promoting self-management in type 2 diabetes mellitus. Rev Esc Enferm USP [Internet]. 2011[cited 2014 Dec 30];45(5):1075-80. Available from: http://www.scielo.br/pdf/reeusp/v45n5/en_v45n5a07.pdf
http://www.scielo.br/pdf/reeusp/v45n5/en...
). Já o telemonitoramento, utilizado por quatro estudos incluídos na revisão(1616 Chen MY, Huang WC, Peng YS, Guo JS, Chen CP, Jong MC, et al. Effectiveness of a health promotion programme for farmers and fishermen with type-2 diabetes in Taiwan. J Adv Nurs [Internet]. 2011[cited 2014 Oct 16];67(9):2060-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21535092
http://www.ncbi.nlm.nih.gov/pubmed/21535...
,2020 Lincoln NB, Radford KA, Game FL, Jeffcoate WJ. Education for secondary prevention of foot ulcers in people with diabetes: a randomized controlled trial. Diabetologia [Internet]. 2008[cited 2014 Nov 18];51(11):1954-61. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18758747
http://www.ncbi.nlm.nih.gov/pubmed/18758...
,2222 Fan L, Sidani S, Cooper-Brathwaite A, Metcalfe K. Feasibility, acceptability and effects of a foot self-care educational intervention on minor foot problems in adult patients with diabetes at low risk for foot ulceration: a pilot study. Can J Diabetes [Internet]. 2013[cited 2014 Nov 13];37(3):195-201. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24070843
http://www.ncbi.nlm.nih.gov/pubmed/24070...
-2323 Kazawa K, Moriyama M. Effects of a self-management skills acquisition program on pre-dialysis patients with diabetic nephropathy. Nephrol Nurs J [Internet]. 2013[cited 2014 Oct 03];40(2):141-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23767338
http://www.ncbi.nlm.nih.gov/pubmed/23767...
), proporciona o acolhimento, a aquisição de conhecimentos e a reflexão sobre o autocuidado, sendo adjuvante nas intervenções(3535 Torres HC, Reis IA, Roque C, et al. Telephone-based monitoring: an educational strategy for diabetes self-care at the primary health care level. Cienc Enferm [Internet]. 2013[cited 2014 Dec 30];19(1):95-105. Available from: http://www.scielo.cl/pdf/cienf/v19n1/art_09.pdf
http://www.scielo.cl/pdf/cienf/v19n1/art...
).

Complicações macrovasculares: doenças cardiovasculares(2121 Rachmani R, Slavacheski I, Berla M, Frommer-Shapira R, Ravid M. Treatment of high-risk patients with diabetes: motivation and teaching intervention: a randomized, prospective 8-year follow-up study. J Am Soc Nephrol [Internet]. 2005[cited 2014 Oct 18];16(1):22-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15938028
http://www.ncbi.nlm.nih.gov/pubmed/15938...
), vasculopatia periférica(1616 Chen MY, Huang WC, Peng YS, Guo JS, Chen CP, Jong MC, et al. Effectiveness of a health promotion programme for farmers and fishermen with type-2 diabetes in Taiwan. J Adv Nurs [Internet]. 2011[cited 2014 Oct 16];67(9):2060-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21535092
http://www.ncbi.nlm.nih.gov/pubmed/21535...
), lesões(2222 Fan L, Sidani S, Cooper-Brathwaite A, Metcalfe K. Feasibility, acceptability and effects of a foot self-care educational intervention on minor foot problems in adult patients with diabetes at low risk for foot ulceration: a pilot study. Can J Diabetes [Internet]. 2013[cited 2014 Nov 13];37(3):195-201. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24070843
http://www.ncbi.nlm.nih.gov/pubmed/24070...
) e úlceras nos pés (1515 Gershater MA, Pilhammar E, Apelqvist J, Alm-Roijer C. Patient education for the prevention of diabetic foot ulcers. Eur Diab Nursing [Internet]. 2011[cited 2014 Oct 16];8(1):102-7b. Available from: http://onlinelibrary.wiley.com/doi/10.1002/edn.189/epdf
http://onlinelibrary.wiley.com/doi/10.10...
,1717 Fujiwara Y, Kishida K, Terao M, Takahara M, Matsuhisa M, Funahashi T, et al. Beneficial effects of foot care nursing for people with diabetes mellitus: an uncontrolled before and after intervention study. J Adv Nurs [Internet]. 2011[cited 2014 Nov 15];67(9):1952-62. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21480962
http://www.ncbi.nlm.nih.gov/pubmed/21480...
-1818 Reda A, Hurton S, Embil JM, Smallwood S, Thomson L, Zacharias J, et al. Effect of a preventive foot care program on lower extremity complications in diabetic patients with end-stage renal disease. Foot Ankle Surg [Internet]. 2012[cited 2014 Oct 02];18(4):283-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23093125
http://www.ncbi.nlm.nih.gov/pubmed/23093...
,2020 Lincoln NB, Radford KA, Game FL, Jeffcoate WJ. Education for secondary prevention of foot ulcers in people with diabetes: a randomized controlled trial. Diabetologia [Internet]. 2008[cited 2014 Nov 18];51(11):1954-61. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18758747
http://www.ncbi.nlm.nih.gov/pubmed/18758...
,2424 Viswanathan V, Madhavan S, Rajasekar S, Chamukuttan S, Ambady R. Amputation prevention initiative in South India: positive impact of foot care education. Diabetes Care [Internet]. 2005[cited 2014 Nov 15];28(5):1019-21. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15855560
http://www.ncbi.nlm.nih.gov/pubmed/15855...
) e amputações(1818 Reda A, Hurton S, Embil JM, Smallwood S, Thomson L, Zacharias J, et al. Effect of a preventive foot care program on lower extremity complications in diabetic patients with end-stage renal disease. Foot Ankle Surg [Internet]. 2012[cited 2014 Oct 02];18(4):283-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23093125
http://www.ncbi.nlm.nih.gov/pubmed/23093...
,2020 Lincoln NB, Radford KA, Game FL, Jeffcoate WJ. Education for secondary prevention of foot ulcers in people with diabetes: a randomized controlled trial. Diabetologia [Internet]. 2008[cited 2014 Nov 18];51(11):1954-61. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18758747
http://www.ncbi.nlm.nih.gov/pubmed/18758...
)

A doença macrovascular diabética caracteriza-se por mudanças estruturais e funcionais em grandes artérias(77 Attridge M, Creamer J, Ramsden M, Cannings-John R, Hawthorne K. Culturally appropriate health education for people in ethnic minority groups with type 2 diabetes mellitus. Cochrane Database Syst Rev [Internet]. 2014[cited 2014 Oct 11];6424(9). Available from: http://www.ncbi.nlm.nih.gov/pubmed/25188210
http://www.ncbi.nlm.nih.gov/pubmed/25188...
). A intervenção implementada no estudo com acompanhamento mais longo (7,7 anos) identificado nesta revisão(2121 Rachmani R, Slavacheski I, Berla M, Frommer-Shapira R, Ravid M. Treatment of high-risk patients with diabetes: motivation and teaching intervention: a randomized, prospective 8-year follow-up study. J Am Soc Nephrol [Internet]. 2005[cited 2014 Oct 18];16(1):22-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15938028
http://www.ncbi.nlm.nih.gov/pubmed/15938...
) foi eficaz em reduzir a ocorrência de eventos cardiovasculares. O estudo realizado com pescadores e agricultores evidenciou, após a intervenção educativa, melhora do índice tornozelo-braquial(1616 Chen MY, Huang WC, Peng YS, Guo JS, Chen CP, Jong MC, et al. Effectiveness of a health promotion programme for farmers and fishermen with type-2 diabetes in Taiwan. J Adv Nurs [Internet]. 2011[cited 2014 Oct 16];67(9):2060-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21535092
http://www.ncbi.nlm.nih.gov/pubmed/21535...
), considerado uma medida de verificação de doença arterial obstrutiva periférica(3636 Nunes FGF, Leão GCS, Exel AL, Diniz MCC. Ankle brachial index in patients at high cardiovascular risk. Rev Bras Cardiol [Internet]. 2012[cited 2014 Dec 30];25(2):94-101. Available from: http://www.rbconline.org.br/wp-content/Archives/v25n2/v25n02a02.pdf
http://www.rbconline.org.br/wp-content/A...
).

A perda sensorial secundária à neuropatia diabética periférica, por vezes, passa despercebida pelo paciente e a primeira apresentação pode ser a úlcera nos pés(3232 Tesfaye S. Recent advances in the management of diabetic distal symmetrical polyneuropathy. J Diabetes Investig [Internet]. 2011[cited 2014 Dec 29];2(1):33-42. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4008012/
http://www.ncbi.nlm.nih.gov/pmc/articles...
). No Brasil, a prevalência de amputações entre indivíduos com pé diabético chega a 58,2%(2929 Santos ICRV, Sobreira CMM, Nunes ENS, Morais MCA. [The prevalence and factors associated with diabetic foot amputations]. Ciênc Saúde Colet [Internet]. 2013[cited 2014 Dec 29];18(10):3007-14. Available from: http://www.scielosp.org/pdf/csc/v18n10/v18n10a25.pdf Portuguese
http://www.scielosp.org/pdf/csc/v18n10/v...
,3737 Tavares DMS, Dias FA, Araújo LR, Pereira GA. Profile of patients submitted to amputation related to diabetes mellitus. Rev Bras Enferm [Internet]. 2009[cited 2014 Dec 30];62(6):825-30. Available from: http://www.scielo.br/pdf/reben/v62n6/a04v62n6.pdf
http://www.scielo.br/pdf/reben/v62n6/a04...
). Além do controle inadequado da glicemia, outros fatores associados à amputação incluem: ausência do exame dos pés durante a última consulta, carência de orientações sobre os cuidados com os pés nas consultas realizadas no ano anterior e a não adesão ao tratamento farmacológico conforme recomendação médica(2929 Santos ICRV, Sobreira CMM, Nunes ENS, Morais MCA. [The prevalence and factors associated with diabetic foot amputations]. Ciênc Saúde Colet [Internet]. 2013[cited 2014 Dec 29];18(10):3007-14. Available from: http://www.scielosp.org/pdf/csc/v18n10/v18n10a25.pdf Portuguese
http://www.scielosp.org/pdf/csc/v18n10/v...
). De fato, nos Estados Unidos há uma variação regional das taxas de amputações de membros inferiores: nas áreas onde há a participação dos indivíduos com DM em aulas sobre autocontrole da doença é menor a ocorrência de amputações quando comparada às regiões em que não ocorre esta participação(3838 McEwen LN, Ylitalo KR, Herman WH, Wrobel JS. Prevalence and risk factors for diabetes-related foot complications in Translating Research Into Action for Diabetes (TRIAD). J Diabetes Complicat [Internet]. 2013[cited 2014 Dec 28];27(6):588-92. Available from: http://www.sciencedirect.com/science/article/pii/S1056872713001736
http://www.sciencedirect.com/science/art...
).

Pacientes com DM e úlcera nos pés têm pior qualidade de vida nos domínios físico, social e psicoemocional(3939 Almeida SA, Silveira MM, Santo PFE, Pereira RC, Salomé GM. Assessment of the quality of life of patients with diabetes mellitus and foot ulcers. Rev Bras Cir Plást [Internet]. 2013[cited 2014 Dec 29];28(1):142-6. Available from: http://www.scielo.br/pdf/rbcp/v28n1/en_24.pdf
http://www.scielo.br/pdf/rbcp/v28n1/en_2...
). O DM de longa evolução (em média 12,5 anos) e sem controle adequado contribui para a ocorrência das úlceras. Igualmente, outros fatores associam-se à presença de úlceras nos pés, como ausência de sensibilidade tátil-pressórica plantar, unhas espessas e calosidades(2828 Martin IS, Beraldo AA, Passeri SM, Freitas MCF, Pace AN. Root causes for the development of foot ulcers of people with diabetes mellitus. Acta Paul Enferm [Internet]. 2012[cited 2014 Dec 29];25(2):218-24. Available from: www.scielo.br/pdf/ape/v25n2/en_a10v25n2.pdf
www.scielo.br/pdf/ape/v25n2/en_a10v25n2....
). Logo, infere-se que intervenções educativas que melhorem os cuidados com os pés não apenas reduzam a chance de desenvolvimento de úlceras nessas regiões, como também favoreçam a qualidade de vida dos pacientes.

Verificar a adesão do paciente à orientação é também item importante que influencia os desfechos clínicos. Estudo realizado no interior do Ceará com idosos do Sistema de Cadastramento e Acompanhamento de Hipertensos e Diabéticos destacou a baixa adesão no autocuidado com os pés, visto que 70,3% dos pacientes com DM utilizavam chinelos, 55,0% não usavam hidratantes e 74,0% cortavam a unha de forma inadequada e não secavam a região interdigital após lavagem(4040 Silva CMG, Vidal ECF. Idosos com diabetes mellitus: práticas de autocuidado. Cad Cult Ciênc [Internet]. 2011[citado 2014 Dec 03];10(2):24-32 Available from: http://periodicos.urca.br/ojs/index.php/cadernos/article/view/40
http://periodicos.urca.br/ojs/index.php/...
). Um dos estudos presente nesta revisão(2424 Viswanathan V, Madhavan S, Rajasekar S, Chamukuttan S, Ambady R. Amputation prevention initiative in South India: positive impact of foot care education. Diabetes Care [Internet]. 2005[cited 2014 Nov 15];28(5):1019-21. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15855560
http://www.ncbi.nlm.nih.gov/pubmed/15855...
) verificou que a recorrência de úlceras nos pés foi menos frequente, e o processo de cura mais rápido entre aqueles que aderiram ao programa, apesar da evolução média do DM desses pacientes ser longa (13,7±7,6 anos).

Os resultados encontrados nesta revisão sobre ocorrência/recorrência de úlceras nos pés após intervenções educativas mostraram-se contraditórios: alguns estudos evidenciaram efetividade(1717 Fujiwara Y, Kishida K, Terao M, Takahara M, Matsuhisa M, Funahashi T, et al. Beneficial effects of foot care nursing for people with diabetes mellitus: an uncontrolled before and after intervention study. J Adv Nurs [Internet]. 2011[cited 2014 Nov 15];67(9):1952-62. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21480962
http://www.ncbi.nlm.nih.gov/pubmed/21480...
,2222 Fan L, Sidani S, Cooper-Brathwaite A, Metcalfe K. Feasibility, acceptability and effects of a foot self-care educational intervention on minor foot problems in adult patients with diabetes at low risk for foot ulceration: a pilot study. Can J Diabetes [Internet]. 2013[cited 2014 Nov 13];37(3):195-201. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24070843
http://www.ncbi.nlm.nih.gov/pubmed/24070...
,2424 Viswanathan V, Madhavan S, Rajasekar S, Chamukuttan S, Ambady R. Amputation prevention initiative in South India: positive impact of foot care education. Diabetes Care [Internet]. 2005[cited 2014 Nov 15];28(5):1019-21. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15855560
http://www.ncbi.nlm.nih.gov/pubmed/15855...
) das ações e outros que não foram efetivas(1818 Reda A, Hurton S, Embil JM, Smallwood S, Thomson L, Zacharias J, et al. Effect of a preventive foot care program on lower extremity complications in diabetic patients with end-stage renal disease. Foot Ankle Surg [Internet]. 2012[cited 2014 Oct 02];18(4):283-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23093125
http://www.ncbi.nlm.nih.gov/pubmed/23093...
) nem eficazes(1515 Gershater MA, Pilhammar E, Apelqvist J, Alm-Roijer C. Patient education for the prevention of diabetic foot ulcers. Eur Diab Nursing [Internet]. 2011[cited 2014 Oct 16];8(1):102-7b. Available from: http://onlinelibrary.wiley.com/doi/10.1002/edn.189/epdf
http://onlinelibrary.wiley.com/doi/10.10...
,2020 Lincoln NB, Radford KA, Game FL, Jeffcoate WJ. Education for secondary prevention of foot ulcers in people with diabetes: a randomized controlled trial. Diabetologia [Internet]. 2008[cited 2014 Nov 18];51(11):1954-61. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18758747
http://www.ncbi.nlm.nih.gov/pubmed/18758...
).

Ressalta-se a dificuldade de comparação e sumarização dos resultados dos estudos incluídos nesta revisão, uma vez que não houve similaridade nos desenhos das intervenções educativas. Além disso, as complicações, enquanto desfechos, foram avaliadas por métodos diferentes, nem sempre validados, e após distintos períodos de acompanhamento.

Nesse sentido, entende-se que a efetividade dos estudos quase experimentais deveria ser confirmada em futuros ensaios clínicos randomizados, com o intuito de reduzir o risco dos vieses de seleção e de aferição, assim comprovando a eficácia das intervenções educativas. Não obstante, os resultados desta revisão apontam possíveis modelos de intervenções educativas a serem testados pelos profissionais de saúde com o objetivo de reduzir as complicações diabéticas.

Algumas limitações desta revisão devem ser consideradas: a restrição do período de abrangência dos dados e a inclusão de artigos disponíveis apenas nos idiomas inglês, português e espanhol.

CONCLUSÃO

Esta revisão identificou que a combinação de diferentes intervenções educativas fornecidas individualmente ou em grupo a pacientes adultos com DM exerce influência na redução de complicações vasculares. As intervenções eficazes envolveram sessões individuais de educação sobre DM e orientações sobre autocuidado realizadas por médicos ou equipe multidisciplinar (médicos, enfermeiros e nutricionistas). Essas ações melhoraram a nefropatia, catarata, retinopatia, neuropatia periférica e eventos cardiovasculares. As intervenções efetivas recorreram a estratégias individuais, envolvendo encontros presenciais e contatos telefônicos realizados por enfermeiros que forneceram orientações sobre cuidados com os pés, dieta, exercícios, controle do estresse e terapia medicamentosa. Tais estratégias reduziram, principalmente, a frequência da neuropatia periférica, as lesões nos pés e a piora da função renal dos pacientes.

Entretanto, há uma lacuna na literatura sobre a efetividade e eficácia das intervenções educativas, visto que nenhum estudo fez referência às complicações metabólicas. Portanto, evidencia-se a necessidade de futuros ensaios clínicos randomizados que analisem o impacto dessas ações na prevenção de complicações diabéticas, sobretudo as metabólicas.

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Datas de Publicação

  • Publicação nesta coleção
    Jul-Aug 2016

Histórico

  • Recebido
    14 Ago 2015
  • Aceito
    15 Fev 2016
Associação Brasileira de Enfermagem SGA Norte Quadra 603 Conj. "B" - Av. L2 Norte 70830-102 Brasília, DF, Brasil, Tel.: (55 61) 3226-0653, Fax: (55 61) 3225-4473 - Brasília - DF - Brazil
E-mail: reben@abennacional.org.br