ABC | Volume 113, Nº4, October 2019

Short Editorial Mill Social determinants of hypertension Arq Bras Cardiol. 2019; 113(4):696-698 1. Mills KT, Bundy JD, Kelly TN, Reed JE, Kearney PM, Reynolds K, Chen J, He J. Global disparities of hypertension prevalence and control: A systematic analysis of population-based studies from 90 countries. Circulation. 2016;134(6):441-50. 2. Mochizuki K, Hariya N, Honma K,Goda T. Relationship between epigenetic regulation, dietary habits, and the developmental origins of health and disease theory. Congenit Anom (Kyoto). 2017;57(6):184-90. 3. Kokubo Y, Padmanabhan SP, Iwashima Y, Yamagishi K, Goto A. Gene and environmental interactions according to the components of lifestyle modifications in hypertension guidelines. Environ Health Prev Med. 2019;24:19. 4. Russo A, Di Gaetano C, Cugliari G, Matullo G. Advances in the genetic of hypertension. The effect of rare variants. Int J Mol Sci. 2018;19(3),Pii:E688. 5. Malachias MVB, Souza WKSB, Plavnik FC, Rodrigues CIS, Brandão AA, Neves MFT e cols. 7ª Diretriz Brasileira de Hipertensão Arterial. Arq Bras Cardiol. 2016;107(3 supl 3):64-6. 6. MaltaDC,GonçalvesRPF,MachadoIE,FreitasMIF,AzeredoC,SzwarcwaldCL. Prevalence of arterial hypertension according to different diagnostic criteria, National Health Survey. Rev Bras Epidem. 2018;21(Suppl 1):e180021. 7. Meyerfreund D, Gonçalves C, Cunha R, Pereira AC, Krieger JE, Mill JG. Age-dependent increase in blood pressure in two different Native American communities in Brazil. J Hypertens. 2009;27(9):1753-60. 8. Santiago ASD, Oliveira JS, Leal VS, Andrade MIS, Lira PIC. Prevalence of systemic arterial hypertension and associated factors among adults from the semi-arid region of Pernambuco, Brazil. Arq Bras Cardiol. 2019; 113(4):687-695. 9. Chor D, Pinho Ribeiro AL, Sá Carvalho M, Duncan BB, Andrade Lotufo P, Araújo Nobre A, et al. Prevalence, awareness, treatment and influence of socioeconomic variables on control of high blood pressure: Results of the ELSA-Brasil tudy. PLoS One 2015;10(6):e0127382. 10. Zaniqueli D; AlvimR; Luiz S; Oliosa P; Cunha RS;Mill J. Ethnicity and arterial stiffness inchildrenandadolescents fromaBrazilianpopulation. JHypertens. 35(11):2257–61. 11. UshakowAV,IvanchenkoVS,GagarinaAA.Psychologialstress inpathogenesis of essential hypertension. Curr Hypertens Rev. 2016;12(3), 203-14. 12. Picon RV, Fuchs FD, Moreira LB, Riegel G, Fuchs SC. Trends in prevalence of hypertension in Brazil: A systematic review with meta-analysis. PLoS One 2012;7(10),e48255. References of the individuals, in the lowest segment the number increased to 44.6%, i.e., the probability of the disease being found was almost 3 times higher in the population segment with a low education level. Considering that education and income are two collinear variables in the Brazilian population, in themultivariate analysis model, schooling level dropped out of the modeling, leaving only the socioeconomic level as an independent predictor of the disease's presence. However, according to the Brazilian standard, both education and income enter into the socioeconomic classification model. What still needs to be further investigated is the mediation between socioeconomic variables (education and income) and blood pressure. The ELSA-Brasil provided some clues on this. 9 Participants of African ancestry (Blacks and Browns) present higher blood pressure and higher blood pressure increase with age, thus predisposing to the onset of HT in adulthood. It is not known, however, whether this difference arises from birth or occurs later. Our research group has been seeking answers by studying children and adolescents of different races/color. We have shown that pre-pubertal students have equal blood pressure values, regardless of race/color. 10 The differences, therefore, appear later in adolescence or, more likely, in adulthood. Psychosocial stress could constitute an important factor in increased pressure with age and, therefore, in the onset of HT. 11 This could explain, albeit in part, the inverse relationship between education/income and HT prevalence. Individuals at the bottom of the social pyramid would live in greater uncertainty regarding their future. The struggle for survival is greater and the social support network related to adverse events in life (unemployment, adverse weather events such as prolonged drought in rural backlands) is less at the base of the pyramid, and this would determine a higher intensity allostatic load on these individuals (increased sympathetic activity, activation of the hypothalamic-adrenal-cortisol axis, attenuation of vagal function) contributing to a faster blood pressure increase over time and contributing to the earlier onset of hypertensive disease. Even without yet understanding where the initial deregulation that would lead to essential HT would be, this chain of events could explain the findings described by Santiago et al. 8 and other authors. This reasoning could explain, in theory, the small decrease in the prevalence of HT in Brazil described by Picon et al. 12 in a meta-analysis based on population-based studies with direct blood pressure measurement. 12 It is noteworthy that in this meta-analysis almost all studies were done in cities in the South and Southeast regions of Brazil, where the population's educational level has been improving in recent decades. Regardless of the mechanism, the data described for the Brazilian population, showing an inverse relationship between education level and HT, pose an additional challenge in addressing the problem. Once diagnosed, the disease must be treated. At this stage, the adoption of healthy lifestyle habits is mandatory in relation to diet (rich in whole grains, fresh fruits and vegetables), physical activity, and quitting smoking and alcohol abuse. If such measures are insufficient for pressure normalization, then medication use enters as an effective measure. However, various factors contribute to the fact that both the adoption of healthy habits, as well as the use of medications, is more difficult for individuals in lower socioeconomic segments. Therefore, those who are most affected by the disease will have less conditions to treat it. Medications, although effective, must be used correctly, as their improper use can do more harm than good. Considering that the gateway to the diagnosis and treatment of HT in our country is the primary care sector, represented by the Primary Care Units, it is essential to engage all health teams, involving doctors, nurses, nutritionists, etc., so that the effectiveness of treatments for the hypertensive population becomes as homogeneous as possible, that is, regardless of socioeconomic factors. On the other hand, the data point to a fact of great significance. Improved education brings about health benefits in general and, particularly, for addressing chronic diseases, such as HT. Investments in education affects favorably the population health. 697