Educational Attainment and Cardiovascular Risk—A Missed Opportunity?—Reply

Abstract

COMMENT & RESPONSEIn Reply We appreciate the thoughtful attention provided by Veronesi and colleagues to our article assessing the lifetime risk between educational attainment and cardiovascular disease. 1 We would foremost urge caution when considering standardization of race-specific percentiles of education as suggested by our colleagues here. Such an approach effectively normalizes vast historical inequities in educational attainment perpetuated by social policy in the US. The legacy and continued perpetuation of structural racism diminishes access to education, quality, attainment, and the resulting social mobility and opportunities afforded by achievement of higher education. 2 Racial differences in the effect of educational attainment in relation to cardiovascular risk in the US are consequently expected. 3 As noted in our article, 1 we appreciate that education is both directly related to health and a proxy for multiple social and structural factors extending from early life to adolescence and beyond. Hence, we would argue that educational attainment in individuals of Black race is necessary to foster health outcomes but insufficient to achieve equitable outcomes comparable with individuals of White race, as demonstrated by our analysis. As a second point of response, we would like to indicate that the birth cohorts of our analysis were similar across cohorts. Considering we had similar findings with stratification by age group (baseline age 40-59 years and 60-79 years), we expect that temporal differences in educational attainment are unlikely to explain our findings. Finally, articulated in the discussion section of our publication, we advocate for the integration of detailed social determinants, such as those pertinent to education, across the life course as standard and essential assessments in commu-nity-based cohorts, registries, and clinical trials. To conduct our analysis, we harmonized data across 6 cohorts that used variable approaches to the collection of data regarding educational attainment. More nuanced and enriched assessments of years of education, educational quality, parental education, concomitant early life socioeconomic exposure, and other relevant social variables will facilitate the more sophisticated analyses suggested by this letter. Such measures are critical to expand our understanding of the impact of social determinants of health on cardiovascular risk.