When the Calculator Is Biased: Rethinking Cardiometabolic Risk Assessment in Indigenous Health
DOI:
https://doi.org/10.18192/uojm.v16iS1.7817Keywords:
cardiometabolic, cardiometabolic risk, Indigenous, ethics, calculation biasAbstract
Cardiometabolic risk assessments are the pillars of our current daily clinical practices, yet they are assumed to be objective and universally applicable. This commentary argues many of the current tools used have not been extensively studied in marginalized populations, especially Indigenous peoples, reflecting colonial assumptions in their development. By reflecting on the ethical and clinical limitations of current models, this article calls for a more collaborative approach with Indigenous governance and culturally grounded approaches to assessing cardiometabolic risk to advance equity in preventative care.
References
1. Valenzuela PL, Carrera-Bastos P, Castillo-García A, Lieberman DE, Santos-Lozano A, Lucia A. Obesity and the risk of cardiometabolic diseases. Nat Rev Cardiol. 2023 Jul 1;20(7):475–94. doi:10.1038/S41569-023-00847-5 PubMed PMID: 36927772.
2. Di Cesare M, McGhie DV, Perel P, Mwangi J, Taylor S, Pervan B, et al. The Heart of the World. Glob Heart. 2024;19(1):11. doi:10.5334/GH.1288 PubMed PMID: 38273998.
3. Gurka MJ, Filipp SL, Pearson TA, Deboer MD. Assessing Baseline and Temporal Changes in Cardiometabolic Risk Using Metabolic Syndrome Severity and Common Risk Scores. Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease. 2018 Aug 1;7(16):e009754. doi:10.1161/JAHA.118.009754 PubMed PMID: 30369320.
4. Shen T, Zhao M, Qiao S, Yang Z, Li M, Zhao M, et al. Management of cardiometabolic risk factors in cardiovascular high-risk populations with varying cognitive levels. Aging Clin Exp Res. 2025 Dec 1;38(1):8. doi:10.1007/S40520-025-03241-Y PubMed PMID: 41460429.
5. Wilson PWF, D’Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB. Prediction of coronary heart disease using risk factor categories. Circulation. 1998 May 12;97(18):1837–47. doi:10.1161/01.CIR.97.18.1837 PubMed PMID: 9603539.
6. Mahmood SS, Levy D, Vasan RS, Wang TJ. The Framingham Heart Study and the Epidemiology of Cardiovascular Diseases: A Historical Perspective. Lancet. 2013;383(9921):999. doi:10.1016/S0140-6736(13)61752-3 PubMed PMID: 24084292.
7. Anderson TS, Wilson LM, Sussman JB. Atherosclerotic Cardiovascular Disease Risk Estimates Using the Predicting Risk of Cardiovascular Disease Events Equations. JAMA Intern Med. 2024 Aug 5;184(8):963. doi:10.1001/JAMAINTERNMED.2024.1302 PubMed PMID: 38856978.
8. Abdul Jabbar A Bin, Inam M, Butt N, Khan SS, Sheikh S, Khoja A, et al. Predicting Risk of Cardiovascular Disease EVENTs (PREVENT) Equations: What Clinicians Need to Know? Curr Atheroscler Rep. 2025 Dec 1;27(1). doi:10.1007/S11883-025-01320-Z PubMed PMID: 40690117.
9. Tanasescu MD, Rosu AM, Minca A, Rosu AL, Grigorie MM, Timofte D, et al. Beyond BMI: Rethinking Obesity Metrics and Cardiovascular Risk in the Era of Precision Medicine. Diagnostics. 2025 Dec 1;15(23):3025. doi:10.3390/DIAGNOSTICS15233025 PubMed PMID: 41374408.
10. Te Vazquez J, Feng SN, Orr CJ, Berkowitz SA. Food Insecurity and Cardiometabolic Conditions: a Review of Recent Research. Curr Nutr Rep. 2021 Dec 1;10(4):243. doi:10.1007/S13668-021-00364-2 PubMed PMID: 34152581.
11. Miguel E da S, Lopes SO, Araújo SP, Priore SE, Alfenas R de CG, Hermsdorff HHM. Association between food insecurity and cardiometabolic risk in adults and the elderly: A systematic review. J Glob Health. 2020 Dec 1;10(2):020402. doi:10.7189/JOGH.10.020402 PubMed PMID: 33110569.
12. Katwal PC, Jirjees S, Htun ZM, Aldawudi I, Khan S. The Effect of Anemia and the Goal of Optimal HbA1c Control in Diabetes and Non-Diabetes. Cureus. 2020 Jun 4;12(6):e8431. doi:10.7759/CUREUS.8431 PubMed PMID: 32642346.
13. Christy AL, Manjrekar PA, Babu RP, Hegde A, Rukmini MS. Influence of Iron Deficiency Anemia on Hemoglobin A1C Levels in Diabetic Individuals with Controlled Plasma Glucose Levels. Iran Biomed J. 2014;18(2):88. doi:10.6091/IBJ.1257.2014 PubMed PMID: 24518549.
14. Walker RJ, Garacci E, Campbell JA, Egede LE. The Influence of Daily Stress on Glycemic Control and Mortality in Adults with Diabetes. J Behav Med. 2019 Oct 1;43(5):723. doi:10.1007/S10865-019-00109-1 PubMed PMID: 31617047.
15. Pérez-Fernández A, Fernández-Berrocal P, Gutiérrez-Cobo MJ. The relationship between well‐being and HbA1c in adults with type 1 diabetes: A systematic review. J Diabetes. 2023 Feb 1;15(2):152. doi:10.1111/1753-0407.13357 PubMed PMID: 36796311.
16. Schultz A, Nguyen T, Sinclaire M, Fransoo R, McGibbon E. Historical and Continued Colonial Impacts on Heart Health of Indigenous Peoples in Canada: What’s Reconciliation Got to Do With It? CJC Open. 2021 Dec 1;3(12 Suppl):S149. doi:10.1016/J.CJCO.2021.09.010 PubMed PMID: 34993444.
17. Vervoort D, Kimmaliardjuk DM, Ross HJ, Fremes SE, Ouzounian M, Mashford-Pringle A. Access to Cardiovascular Care for Indigenous Peoples in Canada: A Rapid Review. CJC Open. 2022 Sep 1;4(9):782. doi:10.1016/J.CJCO.2022.05.010 PubMed PMID: 36148252.
18. Lucero AA, Lambrick DM, Faulkner JA, Fryer S, Tarrant MA, Poudevigne M, et al. Modifiable Cardiovascular Disease Risk Factors among Indigenous Populations. Adv Prev Med. 2014;2014:547018. doi:10.1155/2014/547018 PubMed PMID: 24649368.
19. Clarke-Grant D. Healthcare Access for Indigenous Communities in Rural Canada: A Narrative Review and Interdisciplinary Framework for Action. Intergovernmental Research and Policy Journal. 2025 Jun 29. doi:10.24095/HPCDP.44.4.01 PubMed PMID: 38597804.
20. Stanley LR, Swaim RC, Kaholokula JK, Kelly KJ, Belcourt A, Allen J. The Imperative for Research to Promote Health Equity in Indigenous Communities. Prev Sci. 2020 Jan 1;21(Suppl 1):13. doi:10.1007/S11121-017-0850-9 PubMed PMID: 29110278.
21. Bullen J, Hill-Wall T, Anderson K, Brown A, Bracknell C, Newnham EA, et al. From Deficit to Strength-Based Aboriginal Health Research—Moving toward Flourishing. Int J Environ Res Public Health. 2023 Apr 1;20(7):5395. doi:10.3390/IJERPH20075395 PubMed PMID: 37048008.
22. Howard M, Tan KL, Jayasekara R. Exploring Ethical, Cultural, and Transnational Competence Among International Healthcare Management Students: An Australian Perspective. J Healthc Leadersh. 2025;17:97. doi:10.2147/JHL.S506361 PubMed PMID: 40093562.
23. Neill A, Montesanti S, Bill L, Verstraeten BSE, Bell RC, Oster RT, et al. Aligning Indigenous and Western Concepts of Health Resource Decision Making in a Western Canadian First Nations Context. Appl Health Econ Health Policy. 2025 Jan 1;24(1):163. doi:10.1007/S40258-025-01004-4 PubMed PMID: 40975841.
24. Quelch J, Aden M, Toombs E, Sanders C, Sinoway C, Mushquash C, et al. Understanding the circle of care: Indigenous service providers’ perspectives on health and well-being. AlterNative: An International Journal of Indigenous Peoples. 2025 Mar 1;21(1):3–10. doi:10.1177/11771801251319274
25. Nguyen NH, Subhan FB, Williams K, Chan CB. Barriers and Mitigating Strategies to Healthcare Access in Indigenous Communities of Canada: A Narrative Review. Healthcare. 2020 Jun 1;8(2):112. doi:10.3390/HEALTHCARE8020112 PubMed PMID: 32357396.
26. Billan J, Starblanket D, Anderson S, Legare M, Hagel MC, Oakes N, et al. Ethical research engagement with Indigenous communities. J Rehabil Assist Technol Eng. 2020 Jan;7:2055668320922706. doi:10.1177/2055668320922706 PubMed PMID: 32612848.
27. Kennedy A, Sehgal A, Szabo J, McGowan K, Lindstrom G, Roach P, et al. Indigenous strengths-based approaches to healthcare and health professions education – Recognising the value of Elders’ teachings. Health Educ J. 2022 Jun 1;81(4):423. doi:10.1177/00178969221088921 PubMed PMID: 35531386.
28. Mir A El, Sousa EB de, Mesina-Estarrón I, Celi LA, Hani M, Benjelloun M, et al. Moving beyond the empty cell: The threat of decontextualized healthcare data. PLOS Digital Health. 2026 Jan 13;5(1):e0001194. doi:10.1371/JOURNAL.PDIG.0001194 PubMed PMID: 41528993.
29. Biles BJ, Serova N, Stanbrook G, Brady B, Kingsley J, Topp SM, et al. What is Indigenous cultural health and wellbeing? A narrative review. Lancet Reg Health West Pac. 2024 Nov 1;52:101220. doi:10.1016/J.LANWPC.2024.101220 PubMed PMID: 39664592.
30. Wispelwey B, Tanous O, Asi Y, Hammoudeh W, Mills D. Because its power remains naturalized: introducing the settler colonial determinants of health. Front Public Health. 2023;11:1137428. doi:10.3389/FPUBH.2023.1137428 PubMed PMID: 37533522.
31. Agbonlahor O, DeJarnett N, Hart JL, Bhatnagar A, McLeish AC, Walker KL. Racial/Ethnic Discrimination and Cardiometabolic Diseases: A Systematic Review. J Racial Ethn Health Disparities. 2024 Apr 1;11(2):783–807. doi:10.1007/S40615-023-01561-1 PubMed PMID: 36976513.
32. Anderson M. Indigenous health research and reconciliation. CMAJ : Canadian Medical Association Journal. 2019 Aug 26;191(34):E930. doi:10.1503/CMAJ.190989 PubMed PMID: 31451523.
33. Biles BJ, Serova N, Stanbrook G, Brady B, Kingsley J, Topp SM, et al. What is Indigenous cultural health and wellbeing? A narrative review. Lancet Reg Health West Pac. 2024 Nov 1;52:101220. doi:10.1016/J.LANWPC.2024.101220 PubMed PMID: 39664592.
34. Garba I, Sterling R, Plevel R, Carson W, Cordova-Marks FM, Cummins J, et al. Indigenous Peoples and research: self-determination in research governance. Front Res Metr Anal. 2023;8:1272318. doi:10.3389/FRMA.2023.1272318/FULL
35. Melro CM, Gilfoyle M, Ballantyne C, Augustine L, Brass G, Rabbitskin N, et al. Engaging Indigenous partners in health service transformation: a framework for sustained engagement built on trust. Res Involv Engagem. 2025 Dec 1;11(1):47. doi:10.1186/S40900-025-00721-3 PubMed PMID: 40361206.
36. Wieman N, Malhotra U. “Two eyed seeing”—embracing both Indigenous and western perspectives in healthcare. The BMJ. 2023;383:p2614. doi:10.1136/BMJ.P2614 PubMed PMID: 37957017.
37. Rosolova H, Nussbaumerova B. Cardio-metabolic risk prediction should be superior to cardiovascular risk assessment in primary prevention of cardiovascular diseases. EPMA J. 2011 Mar;2(1):15. doi:10.1007/S13167-011-0066-1 PubMed PMID: 23199124.
38. Marques MDC, Pires R, Perdigão M, Sousa L, Fonseca C, Pinho LG, et al. Patient-Centered Care for Patients with Cardiometabolic Diseases: An Integrative Review. J Pers Med. 2021 Dec 1;11(12):1289. doi:10.3390/JPM11121289 PubMed PMID: 34945763.
39. Mashford-Pringle A, Pavagadhi K. Using OCAP and IQ as Frameworks to Address a History of Trauma in Indigenous Health Research. AMA J Ethics. 2020 Oct 1;22(10):E868–73. doi:10.1001/AMAJETHICS.2020.868 PubMed PMID: 33103649.
40. Sehgal A, Henderson R, Murry A, Crowshoe L, Barnabe C. Advancing health equity for Indigenous peoples in Canada: development of a patient complexity assessment framework. BMC Primary Care. 2024 Dec 1;25(1):144. doi:10.1186/S12875-024-02362-Z PubMed PMID: 38684966.
41. Lafontaine A. Indigenous health disparities: a challenge and an opportunity. Canadian Journal of Surgery. 2018 Oct 1;61(5):300. doi:10.1503/CJS.011718 PubMed PMID: 30246975.
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2026 Aishwarya Rajesh Krishnan
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
- Authors publishing in the UOJM retain copyright of their articles, including all the drafts and the final published version in the journal.
- While UOJM does not retain any rights to the articles submitted, by agreeing to publish in UOJM, authors are granting the journal right of first publication and distribution rights of their articles.
- Authors are free to submit their works to other publications, including journals, institutional repositories or books, with an acknowledgment of its initial publication in UOJM.
- Copies of UOJM are distributed both in print and online, and all materials will be publicly available online. The journal holds no legal responsibility as to how these materials will be used by the public.
- Please ensure that all authors, co-authors and investigators have read and agree to these terms.
- Works are licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
