A New Risk Factor for Cardiovascular Disease and Associated Risk Factors: Education

In this issue of the Journal, Di Chiara and colleagues1 conducted a cross‐sectional study in which they evaluated the association between low education and higher global cardiovascular risk. The study included 228 outpatients (128 women) in a low education group (<10 years of education) and 260 outpatients (120 women) in a medium‐high education group (10–15 years of education). Individuals with psychiatric illness or alcohol use disorder were excluded. Left ventricular mass index and ejection fraction were measured by echocardiography and E/A ratio was measured by pulsed‐wave Doppler. Visceral obesity, hypertension, metabolic syndrome, and microalbuminuria were measured for both groups. A regression model was used to test the independent role of education level and cardiometabolic markers for global cardiovascular risk.

In brief, the authors concluded that low education was associated with a significantly higher prevalence of visceral obesity, hypertension, metabolic syndrome, and microalbuminuria, thus demonstrating greater global cardiovascular risk associated with lower education in this urban population in Sicily.

As a social determinant of health, the link between education and health is being increasingly studied worldwide, with special attention to noncommunicable diseases (NCDs) in global public health. Two of every three deaths in the world result from NCDs, with four of five deaths in low‐ and middle‐income countries.2 As a result, NCDs are widely recognized as a socioeconomic development issue worldwide.3

In 2008, World Health Organization released a report on its Commission on Social Determinants of Health, which details many underlying social factors that contribute to global health disparities.4 Not surprisingly, the first recommendation to improve daily living conditions for disadvantaged populations is to improve education for girls and boys everywhere. Without this, nutrition, psychosocial development, earning potential, and preventive medicine all suffer.

Preventive medicine is inherently linked to NCDs through the primary health care management of chronic disease. According to the Lancet's landmark Global Burden of Disease 2010 study, hypertension is now the number one risk factor for causing disease worldwide, and, consequently, ischemic heart disease is the leading cause of disability‐adjusted life years. This has not always been the case, and the shift from infectious diseases to NCDs is considered a major epidemiological transition in recent history.5

This epidemiological shift can be understood through three rapid transitions: population growth and aging are increasing the disease burden from NCDs; improved education and rising income are leading to decreased mortality from infectious, maternal and child, and nutritional diseases; and people are living longer with chronic diseases: “what ails you is not what kills you.”6

Like education, the association of culture to health is increasingly being explored. First, global health has transitioned from a disease‐oriented approach to a systems‐focused strategy, which involves all stakeholders that govern and maintain healthy societies.7 Similarly, health education worldwide is reorganizing its priorities into interprofessional, systems‐based frameworks that call for improving our educational focus for both patients and health professional students.8 Of course, each of these approaches require culturally appropriate design and interventions to succeed.

In the 2014 Lancet Commission on Culture and Health, health and culture were considered to be so closely interrelated that “disentangement is impossible.9 From this perspective, the role of education in shaping one's cultural understanding of health and well‐being is essential.

At the patient level, Kleinman's Eight Questions are recognized as an important tool for providers to gauge their patients' understanding of health and well‐being. These questions ask patients what they call the problem at hand, what they believe is the cause of the problem, how does this problem affect their body and mind, and others.10 A compelling illustration of this patient‐centered interview is eloquently captured by a recent study on culture and health: “In our country tortilla doesn't make us fat: cultural factors influencing lifestyle goal‐setting for overweight and obese urban, Latina patients.”11

To illustrate strategies to provide culturally appropriate health care worldwide, task shifting is emerging as a key approach to combating NCDs at the community level. Task shifting takes evidence‐based health care services out of the hands of the relatively few physicians and other health‐care system leaders, who often do not share the same cultural background as communities they serve, and into the hands of community health workers and other frontline primary health‐care professionals, who have a greater workforce supply, come from and live in the communities they serve, and typically share the same cultural and educational background as their patients.

For example, in Cameroon, only one in five primary health‐care (nonphysician) clinicians could correctly identify the definitions of arterial hypertension or choose the appropriate first‐line treatment for hypertension. After a targeted community health education intervention, 80% could define hypertension appropriately and 94% could select appropriate treatment.12 In this way, this study clearly defines an essential link between education, culture, and NCDs.

Nonetheless, the link between education and health is still a mystery in many ways, and how to impact behavior change for both patients and practitioners is even more challenging. Bearing all this in mind, the study by Di Chiara and colleagues is an important one that expands on previous findings and stimulates further research. Specifically, with this epidemiological link between education and health better defined, more studies are needed to define evidence‐based interventions that demonstrate appropriate culturally appropriate behavior change to improve outcomes in cardiovascular disease and NCDs in southern Italy and worldwide.

Disclosures

The authors have no conflicts of interest to declare.