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56 million people died in 2015, many prematurely and most (71%) from non-communicable diseases (NCDs).1 Yet NCDs were absent from the UN Millennium Development Goals (MDGs), which expired in 2015.2 Recognising this absence, WHO has set member states a goal to reduce premature mortality from the major NCDs by 25% by 2025 (the 25 × 25 goal).3 To achieve this goal, WHO urges action on seven established NCD risk factors.3 In The Lancet Silvia Stringhini and colleagues4 argue that these risk factors are not enough. Instead, they would have us address an additional (eighth) risk factor: low socioeconomic status (social rank). Having low social rank means being powerless to determine your own destiny, deprived of material resources, and limited in the opportunities open to you, which—the authors imply—shapes both your lifestyle and your life chances.
Stringhini and colleagues4 base their argument not on political ideology but on rigorous science: an original multicohort study of 1·7 million adults followed up for mortality (all cause and by cause) for an average of 13 years. All risk factors (low occupational class, physical inactivity, high alcohol intake, current smoking, obesity, diabetes, and hypertension) were measured with the same relative precision, enabling fair comparison as predictors of mortality. Risk models were both minimally and mutually adjusted, controlling confounding and enabling attenuation (the extent of mediation of one risk factor by another) to be assessed. Finally, estimates of risk factor prevalence and effect were combined to estimate impacts (population attributable risks)—the fraction of all deaths that could potentially be prevented if exposure of the population to the risk factor of interest was reduced to the minimum risk level./.../