ABC | Volume 113, Nº4, October 2019

Short Editorial Social Determinants of Hypertension José Geraldo Mill 1,2 Departamento de Ciências Fisiológicas do Centro de Ciências da Saúde - Universidade Federal do Espírito Santo, 1 Vitória, ES – Brazil Hospital Universitário Cassiano Antônio Moraes - Universidade Federal do Espírito Santo, 2 Vitória, ES – Brazil Short Editorial related to the article: Prevalence of Systemic Arterial Hypertension and Associated Factors Among Adults from the Semi-Arid Region of Pernambuco, Brazil Mailing Address: José Geraldo Mill • Departamento de Ciências Fisiológicas da UFES - Avenida Marechal Campos, 1468. Postal Code 29042-770, Vitória, ES – Brazil E-mail: jose.mill@ufes.br Keywords Hypertension; Hypertension/prevention and control; Prevalence; Risk Factors;Obesity;DiabetesMellitus, Epidemiology. DOI: 10.5935/abc.20190220 Hypertension (HT) is a disease with high prevalence in adults and is generally referred to as a 'complex disease'. This term has been used to indicate the diversity of factors that contribute to its onset. 1,2 Studies in populations, twins, and families estimate that the impact of genetic background on the onset of HT ranges from 34% to 64%. 3 However, pressure regulation depends on a multiplicity of organs, systems, and mechanisms, which is why a large number of genes affect individual values. As a result, genetic tests are still largely ineffective as predictors of HT, since monogenic inheritance of this disease is rare. 4 Non-genetic factors are also numerous and are linked to lifestyle (nutrition, physical activity, alcohol and tobacco consumption, among others) or to the presence of conditions connected with a chronic inflammatory state, such as obesity and insulin resistance. In the presence of these factors, blood pressure increase with age is faster, leading to, at a given moment, blood pressure levels indicative of the presence of the disease. It is important to point out that the cutoffs that separate the states of 'normotension' and 'hypertension' are statistical, being suitable for use with populations, and potentially unsuitable in assessing individuals, 5 as the disease may be present in a subclinical state, i.e., even before reaching diagnostic blood pressure levels obtained in epidemiological studies. Therefore, given the difficulty of using genetic data, disease prevention should be undertaken by identifying risk factors that contribute to raising blood pressure. In this context, epidemiological knowledge about specific populations is an essential tool for handling the disease. Despite its high impact on morbidity and mortality, and on economic and social costs, the epidemiology of HT and its determinants are still poorly known for the Brazilian population. Only in recent years has a robust and nationwide study been conducted in this area. The large territorial extent and the racial and cultural diversity of the Brazilian population also require regional studies. The National Health Survey ( PNS ) conducted in 2013 by the Ministry of Health with support from the IBGE [Brazilian Geography and Statistics Institute) in a representative and robust sample (N > 60 thousand) of the Brazilian adult population, showed a self-reported prevalence of HT of 21.4%, more frequent in women (24.2%) than men (18.3%). Upon changing the diagnostic criterion, considering those with blood pressure measured at home≥140/90mmHg, or those taking antihypertensive drugs, as individuals with HT, the prevalence rose to 32.3%, with a higher prevalence inmen. 6 The study also showed differences between regions, with lower prevalences seen in the North and Northeast and higher ones in the South and Southeast. The disease was also less frequent in rural residents. Part of the regional differences may stem from different race/color compositions. Indigenous peoples apparently have lower blood pressure readings 7 and this may translate into a lower impact of the disease on populations with a greater presence of the indigenous trait, such as in the Northern region. Regional differences may also stem from the uneven distribution of general factors that affect blood pressure regulation, such as high salt intake, body fat accumulation, physical inactivity, alcohol abuse, and insulin resistance. The large territorial extent and cultural diversity may contribute to the non-uniform distribution of these factors and, consequently, the variability in the distribution of HT and other chronic diseases. More recently, the role of socioeconomic variables in the emergence, progress, and outcomes related to blood pressure is being viewed with increasing importance. Large studies, such as the Longitudinal Study of Adult Health ( ELSA-Brasil ), show the impact of low education and income levels on increased blood pressure and on the prevalence of the disease. 8 These data indicate that the Brazilian population segment living inmore unfavorable conditions is more subject to the impact of the disease. And this has important consequences for addressing this health problem. In this issue of the Arquivos Brasileiros de Cardiologia [Brazilian Cardiology Archives], Santiago et al. 8 publish data on a population-based study aimed at identifying the characteristics and prevalence of HT in the adult population (20‑59 years) residing in the semiarid region of Pernambuco, in the Northeastern region of Brazil. 8 For this purpose, a representative sample of urban and rural households was selected by drawing from census tracts from three municipalities. The study showed that the overall prevalence of HT was 27.4%, with a predominance inmales. Despite not having the statistical power for more detailed analyses of subgroups, it is clear from the data that the disease affects, with greater impact, the population segments with lower education and income, two variables that are represented in the socioeconomic classification of the households. The association between the presence of the disease and low education is impressive. While in the segment with higher education the presence of HT was found in 15.4% 696