Correspondence on “Association of low knowledge about cardiovascular disease and lack of lifestyle changes after the COVID-19 pandemic with higher cardiovascular risk in Peruvian residents”

Dear Editor,

We would like to comment on the recent publication by Barreto-Vega et al. ¹ : “Association of low knowledge about cardiovascular disease and lack of lifestyle changes after the COVID-19 pandemic with higher cardiovascular risk in Peruvian residents.”

The authors themselves acknowledge several limitations, including that participants were recruited from Lima East only, and that non-probabilistic sampling limits generalizability. The article presents a cross-sectional study, which – as the authors also recognize – can reveal associations between variables but not causal inference. Therefore, the observed association between lack of lifestyle modification following COVID-19 and higher cardiovascular risk should be interpreted with caution, as causality cannot be inferred.

Furthermore, data on knowledge, attitudes, and practice was self-reported, which the authors also note may introduce social desirability or recall bias, particularly regarding post-pandemic lifestyle changes or knowledge of heart disease. This could lead to over- or underestimation of the associations observed. The 371 participants were selected via convenience sampling, although the exact technique for recruiting participants is not specified. Thus, one can question the generalizability of results even for the population of Lima East.

The study conducted statistical analysis using robust variance Poisson regression to calculate the prevalence ratio (PR), which is appropriate for prevalence ratio data. However, it remains important to clarify which confounders were included in the multivariate model, since age, gender, BMI, and comorbidities can influence cardiovascular risk. Reporting only confident interval (CI) may be insufficient; examining model goodness-of-fit could improve the robustness of the analysis.

Perhaps a more important consideration is that the study relies on specific measurement instruments such as the “Knowledge about Cardiovascular Disease questionnaire” and the “Changes in lifestyle during the quarantine period.” While these tools provide structured data, their validity and reliability in the Peruvian population are not fully detailed. Without strong cultural adaptation and psychometric validation, the risks exists that the instruments may not accurately capture participants’ true knowledge levels of lifestyle behaviors. This limitation is crucial because any measurement bias could directly affect the association reported between knowledge, lifestyle changes, and cardiovascular risk. Future research should explicitly report such instruments should be piloted, and possibly modified, for their appropriateness in new cultural settings.

To broaden the discussion, researchers could pose additional questions, such as: Why are people who do not change their lifestyle at a higher risk? Which lifestyle behaviors have the greatest influence on risk? Further exploration of the knowledge-behavior gap, including individuals who know about risk but do not act, may help advance our understanding.

Barreto-Vega et al. conclude that failing to change one’s lifestyle following COVID-19 is related with a 3.34-fold increase in heart disease risk, demonstrating that health habits have a clear impact on risk even with limited awareness of heart disease. “Their finding highlights the potential impact of improved health behaviors even with limited knowledge of cardiovascular disease; none the less, causality cannot be established.”

The results of this study suggest that emphasis should be placed on motivating and assisting people to modify their health behaviors. While this is important, further investigation might show that specific, vulnerable groups – such as elderly people or patients with underlying medical issues – may require more than verbal encouragement, that is, secondary prevention policies or clinical interventions.

Hinpetch Daungsupawong Private Academic Consultant, Phonhong, Lao People’s Democratic Republic Viroj Wiwanitkit Department of Research Analytics, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences Saveetha University, Chennai, India