Multidisciplinary Primary Care Intervention for Diabetes and Hypertension: Glycemic Control and Cardiovascular Risk Reduction in Vulnerable Populations

Resumen

Introduction: Diabetes mellitus (DM) and systemic arterial hypertension (SAH) disproportionately burden vulnerable populations, exacerbating cardiovascular risks and healthcare disparities. The HiperDia program in Itabuna, Bahia, addresses these comorbidities through integrated care. Multidisciplinary strategies, integrating medical, nutritional, and community-based interventions, are critical for effective management in resource-constrained settings. Objective: To evaluate the efficacy of a multidisciplinary intervention within the HiperDia program for managing DM and hypertension in vulnerable populations, focusing on glycemic control, blood pressure, and treatment adherence. Methods: A 12-month prospective cohort study was conducted at the HiperDia unit in Itabuna, Bahia, involving low-income patients. One hundred patients with type 2 DM and SAH were enrolled. The intervention comprised: (1) optimized pharmacotherapy, (2) nutritional counseling, (3) tailored physical activity programs, and (4) education delivered by community health workers. Primary outcomes included changes in HbA1c, fructosamine, systolic blood pressure (SBP), medication adherence (Morisky Scale), and quality of life (SF-36). Mixed-effects models adjusted for age, sex, and comorbidities were used for analysis. Results: The intervention reduced HbA1c by 1.2% (95% CI: 0.9–1.5, p<0.001), fructosamine by 30% (95% CI: 22.5–36.8, p<0.001), and SBP by 12.4 mmHg (95% CI: 10.1–14.7, p<0.001). Medication adherence improved by 28% (p<0.01), with 72% achieving high adherence. Quality of life significantly improved (p<0.05). Women and patients aged ≥60 years exhibited greater benefits. Loss to follow-up was 8%. Conclusion: The HiperDia multidisciplinary intervention significantly enhanced glycemic and blood pressure control, adherence, and quality of life. Scaling these strategies could mitigate disparities and improve cardiovascular outcomes in vulnerable populations.