Life Course Education, Health, and Ageing Well: A Short Inter-Academic Report

After the first wave of the COVID-19 pandemic, during which the severity of the disease in certain countries was attributed to a lack of basic education of the inhabitants, the authors of this paper initiated a literature review of educational trajectories, health, and ageing well. The findings strongly demonstrate that alongside genetics, the affective and educational family environment, as well as the general environment, greatly interact starting from the very first days of life. Thus, epigenetics plays a major role in the determination of health and disease [DOHAD] in the first 1,000 days of life as well as in the characterization of gender. Other factors such as socio-economic level, parental education, schooling in urban or rural areas, also play a major role in the differential acquisition of health literacy. This determines adherence (or lack thereof) to healthy lifestyles, risky behaviours, substance abuse, but also compliance with hygiene rules, and adherence to vaccines and treatments. The combination of all these elements and lifestyle choices facilitates the emergence of metabolic disorders (obesity, diabetes), which promote cardiovascular and kidney damage, and neurodegenerative diseases, explaining that the less well educated have shorter survival and spend more years of life in disability. After having demonstrated the impact of the educational level on health and longevity, the members of this inter-academic group propose specific educational actions at three levels: (1) teachers and health professionals, (2) parents, (3) the public, emphasizing that these crucial actions can only be carried out with the unfailing support of state and academic authorities.

© 2023 S. Karger AG, Basel

Introduction

The ongoing pandemic has prompted different behaviours and reactions from all populations affected by SARS-CoV-2. The observation of these divergent attitudes, ranging from total compliance with recommended health rules, to outright revolt against all initiatives to protect individual and collective health, prompted us to engage in more general reflection about the impact of basic education and health literacy on health and ageing. The two fundamental questions that we sought to elucidate were:

• Firstly, what role(s) does life course education play on lifestyle habits, global health, and the ability to age well and

• Secondly, does education play any role in the occurrence of the most frequent diseases or have any impact on life expectancy.

Members of the French and Mexico Academies of Medicine review here the large body of evidence affirming the significant role of education on health and ageing. Then, we propose concrete actions in targeted populations, to leverage the role of education to improve health and promote successful ageing.

Materials and Method

To answer the research questions identified, the members of the French and Mexico Academies of Medicine project first specified their working definitions of education, basic education, health education, or health literacy, and then sought to identify the links that existed between these different areas of knowledge.

Education

Among the multiple etymological origins of the word “education,” the authors have chosen to define education as the act of bringing the child out of his/her primary state or of bringing out of him what he/she virtually possesses [1]. Education is therefore about developing, doing, producing, and transmitting knowledge and skills.

Basic Education

According to the UNESCO, basic education includes primary education [first stage of basic education] and lower secondary education (second stage) to read, calculate, and understand, to meet specific-basic educational needs of groups of people of all ages. The comparison between the French and Mexican education systems clearly shows that the financial investment is higher, and the average duration of studies is longer in France, where early school drop-out is less frequent. Alarmingly, the illiteracy rate among those over 65 is very high in both countries, explaining many problems of simple comprehension [2]. In this regard, illectronism levels measured before the recent pandemic among middle-aged French people, reached 20% overall, and over 80% among those aged over 65 [3]. Illiteracy rates are similar in the Mexican population (Table 1).

Table 1.

Comparison of the educational systems in France and Mexico

Comparison of the educational systems in France and MexicoFranceMexico6.7%Education as % of the gross domestic product (GDP)5.7%18.3 yearsAverage number of years of education9.7 years40%Percentage with long education (>14 years)20%12%Percentage of early exits from the education system20%Gender and rural-urban inequalities9%Illiteracy between 18 and 25 years<5%30%Illiteracy in those over 6526%20%Illectronism between 18 and 25 years?Health Literacy

According to [2], the process of developing health knowledge has several stages. The first step is access to health information, which depends on basic education, interest, and individual motivation. The next steps involve understanding the information and critically evaluating it, before then making an informed decision. This individual process is dependent on many environmental factors, both structural and societal, which intervene at each stage. The study of health learning highlights that we are not all equal in our ability to make appropriate choices in a complex health system [1]. Unfortunately, few or no studies have assessed the health literacy of both French and Mexican populations.

Relationship between Basic Education and Health Literacy

There is a proven link between poor basic education and poor health literacy. However, a good basic education is no match for quality health literacy. Regardless of the basic educational level, poor health literacy can explain the relationships with poorer perceived health, hence the possible increase in perceived good health with better health education [4]. Having clarified these essential definitions, we decided that the only way to approach this theme was to apprehend it in a holistic manner, across the life course.

Due to the pandemic, specific questions were sent in writing to a panel of experts from the French and Mexican Academies of Medicine. Numerous written and virtual exchanges reflecting professional experience, bibliographical contributions, and the opinions of the consulted experts generated a preliminary report, which was circulated to all the participants, on both sides of the Atlantic, for approval.

What Role(s) Does Life Course Education Play on Lifestyle Habits, Global Health, and the Ability to Age Well?

Everyone agrees that human life starts at conception, to finish at an ever-older age. The life trajectory is heavily dependent on constant interactions between the individual’s characteristics and the general life environment [5]. In parallel, education is known to develop and impart knowledge and skills that enable people to make choices in accordance with their desires, preferences, and priorities. This supposes that education helps one to acquire general knowledge, develop the powers of reasoning and judgment, and more generally, prepare oneself or others intellectually for mature life [6]. This includes adopting healthy habits in terms of behaviours, general hygiene, food choices, physical activity, and other life habits.

Genetic Heritability and the Importance of Environmental Factors (Epigenetics)

Heritability has no fixed value for a given attribute such as intelligence. Whatever the theory, there is no single metric that can quantify heritability or that represents a true and constant value for the heritability of the intelligence quotient (IQ) (which is not equivalent to intelligence) [7]. Heritability is dependent on numerous factors, including close link between the individual’s genetics and their living environment. Based on these 2 dynamics, there are complex and continuous interconnections throughout life, and education shapes the cognitive functions of each. Thus, family environmental factors (e.g., the quality of maternal care, characteristics, beliefs, living environment, socio-economic and cultural status of parents), as well as extrinsic factors (positive or negative life experiences, malnutrition, accident, disease, stress, or abuse) will, from an early age, promote, or diminish learning skills [8]. Socio-economic status interferes directly with the long-term evolution of IQ. In a follow-up study of children from the age of 22 months to 10 years with various levels of IQ, it was shown that cognitive development improved in the wealthiest socio-economic surroundings, while it worsened in children who grew up in families of low socio-economic position [9].

Education and Orientation of Sexual Life

If men and women are distinguished medically, it is because the differences linked to sex are expressed in the smallest of their cells [4]. To speak of “sex” is to refer only to the biological and physiological characteristics that differentiate men from women from the moment of conception. “Gender,” on the other hand, designates the roles, behaviours, and attributes that are differentiated and socioculturally determined by the fact that society considers them to be socially appropriate for males or females, but only from birth onwards. Since the 1980s, the two terms are no longer interchangeable, thanks to a new science, namely, epigenetics, which fills the age-old gap between the innate and the acquired. Education obviously plays a major role in the occurrence and sustainability of these changes [10].

Early Childhood and Pre-school Age

The developmental origins of health theory indicate that intrauterine development and development during the earliest years of life are critical phases during which susceptibility to many chronic diseases is established. This concept, called Developmental Origins of Health and Disease (DOHaD), suggests that these diseases often only reveal themselves if the environment and lifestyle are conducive [11]. Exposure to unbalanced nutrition, infectious or non-infectious agents, or to psychosocial stress during the prenatal period or in the first months of life is factors for which long-term adult consequences on the health of individuals have been shown. It therefore appears legitimate to ensure the best possible conditions for the early biological, physical, emotional, and cognitive development of children. In a prospective sample of 10,652 English children [the Millennium cohort] followed from birth to age 14, repeated periods of malnutrition (food intake below 60% of requirements) were shown to be at the origin of obesity, risky behaviours, and chronic diseases [12]. It is also clear that the parental environment provided by education also plays a major role. It was shown in a recent French study that during the first 2 years of life, the acquisition of language (and not motor skills) was significantly higher if the mother had a high educational level or if she belonged to a high socio-economic level [13].

School Age and Basic Educational Skills

School appears to be the ideal place to promote physical and mental health, well-being, and educational success because of the community of young people to be found there, the length of time they spend there, and the recognized influence of the school environment, second in importance immediately after the family. School also offers the possibility to promote the commitment of parents, who generally want their children to benefit from the best learning conditions. It is the very mission of schools to contribute to the development of the basic skills that enable children to develop, both in terms of their health and their educational success.

However, this is not always the case, as illustrated by French government statistics. In the year 2011/2012, in France, 16% of the metropolitan population experienced difficulties in the fundamental skill of writing, and 7% of those were educated in France were illiterate, representing in total 2.5 million people [3]. Overall, illiteracy concerned mainly adults over the age of 60 years who were educated in a foreign language outside of France (61%), more specifically men (60.5%) living in rural areas or small towns (30%). These alarming data are unfortunately common in other European countries (Germany and Italy) and are quite equivalent at the OECD mean level [14], which testifies to the importance of boosting the basic educational level of the global population. This refers not only to illiteracy but also to acalculia [15] and digital illiteracy, which mainly affect the older generations [16].

Any discussion of school education would be incomplete without recalling the close relationship that exists between education and socio-economic level. Education allows the acquisition of know-how, the basis of psychological, social, and financial achievement. The profession brings prestige and responsibilities but also risks, while financial income translates power, position in society and the possibility of adopting a healthy lifestyle, and accessing high-quality preventive and, above all, curative care.

Interaction between Children’s Education and Socio-Economic Level of Parents

If in adolescents, non-cognitive skills such as lifestyle habits and social behaviours, largely explain the association between education and health, in adults, this link is more related to cognitive skills (i.e., knowledge acquired). The question is whether more educated people have better health because they are more educated or whether they are more educated because they have better health [17]. Despite the many confounding factors (income, social position, smoking, habits/behaviours, etc.), two theories have emerged. The first is the theory of “fundamental causes of health and disease,” which postulates that among the social factors, education greatly influences the state of health because it determines access to a multitude of material and immaterial resources that all protect or improve health [18]. The second is the “human capital” theory, which states that education improves knowledge, skills, reasoning, efficiency, and a wide range of other abilities, which can be used to maintain good health.

Differences between Raising Children in Rural and Urban Areas

The world population has increased from 2.5 billion people in 1950 to 7.8 billion in 2020, and it will continue to grow strongly and to peak at an estimated 9.7 billion in 2050 [19]. At the same time, the world’s urban population has increased from 746 million in 1950 to 4 billion in 2020. By 2050, this number is expected to reach 6.4 billion, meaning that two-thirds of the world’s entire population will live in urban areas [18]. In these conditions, it appears logical to anticipate the possible impact of urbanization on education and health, bearing mind that unattractive rural margins, far from the coast and major urban centres, combine the lowest level of education and the most unfavourable health status indicators [20].

Education and Environmental Concerns

Several studies have established that education, formal [through education and schooling] and informal (through family socialization), can have direct and indirect effects on environmental concerns but also on the individual pro-environmental behaviours that result. A higher level of education seems to promote an enhanced understanding of the risks associated with environmental deterioration, and the need to preserve natural resources [21]. Considering animal health [domestic animals and wildlife], preserving the balance and health of the different ecosystems, and the “one health” concept should help preserve human health [22]. According to this concept, education should not only deal with humans but more generally with all living things and integrate all notions of health into a broader vision of the preservation of biodiversity. It is thus a question of promoting multidisciplinary training without omitting the education of the populations on the risk entailed by any modification of the ecosystems and the disruption of biological balance.

Education and Lifestyle

Regular physical activity is practiced by half of people with a higher education level, whereas fewer than 20% of those with no diploma engage in regular exercise [23]. The latter eat at least one fruit or vegetable per day 2–4 times less often than their more educated counterparts. In addition, consumption of tobacco among the less well educated is 4 times higher, although alcohol consumption is roughly equivalent [except express alcoholism] to that observed among individuals with third-level education [24]. All these results explain a rate of overweight and obesity reaching 60.8% and 53.4%, respectively, among men and women without a diploma [21]. Poor diet, rich in saturated fatty acids of animal origin, carbohydrates, and sodium chloride, consumed from childhood onwards, continues to affect a large part of the population, especially disadvantaged social strata, because of its moderate cost. Taken together, these factors promote the subsequent development of cardiovascular diseases (CVDs). Accordingly, it has been shown in numerous international studies that adults who have not benefited from higher education have approximately twice the risk of developing CVD (coronary or cerebrovascular disease) [2527].

Education and Hygiene

Due to demographic growth, ongoing climate change, and imbalances in the various ecosystems (deforestation, new irrigation dam projects, changing industrial and agronomic practices), humanity is at the mercy of iterative risks of pandemics. In this context, the practice of hygiene, a concept linked to cleanliness, health, and medicine, makes it possible to prevent and reduce the incidence and spread of infectious diseases.

Preventing and controlling infections require an understanding of the factors related to their spread. Prevention through individual hygiene (hand washing, mouth hygiene, cleaning, disinfection, sterilization, vaccination, surveillance) and collective hygiene (distancing, wearing masks, public isolation measures, curfew, lockdown, or quarantine) are very dependent on the educational, cultural, and socio-economic context.

Education and Vaccine Adherence

The COVID pandemic has helped highlight this concern in countries all around the world, although vaccines are the subject of reluctance and rejection linked to public education, illiteracy, false rumours, and lack of information [28]. Low basic education, insufficient health knowledge, and the level of confidence in vaccination among the population combined with a lack of communication skills among health professionals leads to low adherence to vaccines among the population, who are unable to estimate the risk-benefit balance of vaccines [29]. A virtual study carried out on a voluntary basis with 1,647 participants over the age of 18, fluent in French and confined to their homes in France, revealed a significant relationship between the inability to analyse fake news, the educational level and vaccine hesitancy or refusal [30].

As regards rumours about vaccination, they have always existed and are currently reaching new heights on social networks. They are based on beliefs used for demagogic purposes, fraudulent acts, and misinformation. Nowadays, it is the composition of vaccines and their possible but exceedingly rare deleterious effects that are the subject of conspiracy controversies. The disinformation reverberates with a significant segment of the population, whose insufficient education leads them to doubt, or even reject vaccines. This lack of confidence in scientific, administrative, or governmental authorities is observed today about SARS-CoV-2, but it also impacts all the other classical vaccines [29].

Does Education Play Any Role in the Occurrence of the Most Frequent Diseases and Has It Any Impact on Life Expectancy?Education Influences the Self-Reported Perception of Health and Mental Health

The analysis of inequalities in 33 OECD and EU countries confirmed that people from disadvantaged socio-economic backgrounds frequently report being in worse health, having higher exposure to risk factors and struggling more to access the health system than the better-off or better educated. Education plays a major role in the constant self-reporting of health between higher and lower educated participants, demonstrating large health inequities in all studied countries [14].

Education, Life Expectancy, Disability-Free Life Expectancy, and Long-Term Care

Measures of inequalities in longevity from 17 OECD countries show that, on average, the gap in life expectancy between high- and low-educated people is 8 years for men and 5 years for women at the age of 25 years; and 3.5 years for men and 2.5 years for women at the age of 65. CVDs, the primary cause of death among the over 65 s, are the primary cause of mortality inequality between the high- and low-educated people [31]. In addition, the less educated, who already have the disadvantage of living a shorter life, also spend more years of life with functional disability [i.e., impairments on the ability to use the telephone, go shopping, take public transport, manage money, take medication regularly or even wash, eat alone, dress, and be continent] compared to those who have had more education (secondary or tertiary). It is well known that people with low or average educational attainment are more likely to have difficult or physically demanding jobs, which in turn increases by 50% the frequency of functional incapacity in this group, compared to people with more years of education [32]. Thus, the main beneficiaries of long-term care are people with primary and secondary education compared to those with tertiary education. As for early deaths, they are related not only to the education of the deceased but also to the education of the surviving spouse, regardless of the age of the deceased [33].

Lifelong Education and Obesity

Obesity, a disease that ignores age, has its roots at the individual, societal, and ecological levels. Obesity is a major problem in terms of both public health and medical implications, given its deleterious consequences for the health of those affected. Among developed OECD countries, the highest adult obesity prevalence is observed in the USA (40%), Chile (34.4%), and Mexico (33.4%), and the lowest in Japan (4.2%) and South Korea (5.5%) [34].

In France, the overall percentage of obesity is 17%, while 16.4% of men and 15.7% of women with a short education are overweight, compared to only 8% and 10.7%, respectively, among those with a longer education. In the same population study, it was found that massive obesity concerns 1.8% and 3.7% of men and women with a low educational level compared to 0.8% and 0.4% of men and women with a higher education level [34]. Moreover, it was shown that across 11 European countries, low maternal education yielded a substantial risk of childhood adiposity [risk ratio 1.58 (95% CI: [1.34–1.85]) [35].

Education in the field of obesity must accord more attention to the concepts of behavioural economics, in particular the place of emotions in mental life [36]. Efficacious lobbying must be considered in an ecological way, to promote the autonomy of people and counterbalance the mechanisms that risk leading them inevitably to obesity, seen as the loss of freedom [37].

Education and Diabetes

It is estimated that in the world today, 537 million adults (aged 20–79 years) are living with diabetes, while 1 in 10 and 541 million adults have Impaired Glucose Tolerance (IGT), which places them at high risk of type 2 diabetes. This explains why the number of diabetic patients is predicted to rise to 643 million by 2030 and 783 million by 2045 [38]. The average age of people with diabetes is 60 years, a quarter of them are 75 years or older. This ever-increasing number is explained by the abandonment of a traditional diet in favour of an industrialized diet, the progression of sedentary lifestyles, and the steady increase in life expectancy.

Low-educated patients suffering from diabetes appear to have more concerns about self-monitoring control of glycaemia and HbA1C and diabetic diet. Moreover, they suffer from more macro- and micro-vascular events, as well as podiatric complications, which explain their early all-cause mortality [hazard ratio 1.34 (95% CI: [1.18–1.52]), p < 0.0001 [39]. These figures underline the urgency of taking this problem into account by political leaders, through a realistic approach to the causes of this disaster, to better prepare an effective response, consisting in limiting the exponential progression of diabetes and reducing its complications.

Lifelong education remains the solution to change this situation. Educational conduct should be based not only on information but also on personalized dialogue with regular monitoring, considering the family, social, professional, and psychological context. The effectiveness of these measures will depend on the commitment of everyone, general practitioners, diabetologists, gynaecologists, cardiologists, and even geriatricians, who must change their approach by giving greater importance to lifelong prevention.

Education and CVDs

CVDs are the leading cause of death globally. An estimated 17.9 million people died from CVDs in 2019, representing 32% of all global deaths. Of these deaths, 85% were due to heart attack and stroke. Over three-quarters of CVD deaths take place in low- and middle-income countries. Out of the 17 million premature deaths (under the age of 70) due to non-communicable diseases in 2019, 38% were caused by CVD. Most CVDs can be prevented by addressing behavioural risk factors such as tobacco use, unhealthy diet and obesity, physical inactivity, and harmful use of alcohol. It is important to detect CVD as early as possible so that management with counselling and medicines can begin [40].

In the Prospective Urban Rural Epidemiology, 155,722 participants who did not have a prior history of CVD were enrolled from 21 countries. Over 70% of the population attributable fraction (PAF) for cardiovascular mortality was attributable to fourteen modifiable risk factors. Among them, low education had the highest PAF (12.5%) for death in the overall population, closely followed by tobacco use, low grip strength, and poor diet (each contributing to less than 10% of the PAF for death). The hazard ratio was 1.18 for persons with little or no education, compared to highly educated individuals in high-income countries, and it reached 2.25 in low-income countries [41].

Public education in the field of CVDs concerns two main situations:

a) Education on the prevention of risk factors for atherosclerotic disease

Educational campaigns must develop knowledge of the major cardiovascular risk factors and their prevention. They must promote healthy lifestyle habits (fight against a sedentary lifestyle, overweight and obesity, smoking), combat defective eating habits (foods rich in saturated fats, salt and carbohydrates, snacking, consumption of sugary drinks) but also increase knowledge of “silent” risk factors (arterial hypertension, hypercholesterolemia, and diabetes).

b) Education in heart failure

Heart failure is a chronic pathology whose incidence increases with ageing. The beneficial effect of involving patients in the management of their disease has long been recognized and encompasses several aspects: identification of the alarm signals that announce the occurrence of a sometimes-sudden decompensation, explanation of the issues, and the effect of the multiple usable therapeutic classes and statement of errors often made from ignorance (high sodium diet, abandonment of treatment) and situations that can lead to sudden worsening (anaemia, prohibited drugs as well as fever and infection), hence the interest of anti-influenza vaccination.

Education and Chronic Renal Failure

It is estimated that worldwide, approximately 10% of adults are affected by some form of chronic kidney diseases (CKDs), resulting in 1.2 million deaths and 28 million years-of-life-lost. According the 2019 Global Burden of Disease study, CKD was ranked 18th in the list of causes of the total number of deaths worldwide and 9th among the population aged 75 and older [42]. This jump up the list is alarming, demonstrating the ineffectiveness of current policies and strategies based on individual risk factors to reduce them, as well as their mortality and costs [43]. CKD, essentially linked to diabetes and arterial hypertension, is a silent disease, which evolves without the slightest symptoms, explaining the high frequency of late diagnoses. In France, one in five patients requires dialysis without ever having seen a nephrologist. When patients with a low educational level (30–50% of cases) learn of their diagnosis and its inevitable progression, sometimes aggravated by external factors (continuation of smoking, taking non-steroidal anti-inflammatory drugs), their psychological distress and the obligation to hastily reorganize their family lives are major [44].

a) Knowledge about CKD, acquired from their family doctor, generally very useful patient associations, popular electronic books, or articles, enables patients to promote kidney health and become actors of their disease management, thereby enabling them to live with it better daily [45].

b) Where possible, the educated patient and a prepared family can increase adherence to treatment, avoid the factors that aggravate progression, and reduce the burden of care (autonomous home dialysis) [46].

Education and Dementia

Worldwide, around 55 million people have dementia, with over 60% living in low- and middle-income countries. As the proportion of older people in the population is increasing in nearly every country, this number is expected to rise to 78 million in 2030 and 139 million in 2050 [47]. A low level of education, assessed by the number of years of formal education or by the highest level of study attained, is often associated with an increased risk of developing Alzheimer’s disease or a related dementia disease in cohort studies [48]. This would perhaps explain the greater frequency of Alzheimer’s disease in women who not only live longer but seem naturally more exposed to expressing the disease at the same age. However, in women whose genetic and family factors are controlled, the educational risk appears not to be significant.

These results are in agreement with the hypothesis that subjects with a high level of education have a greater cerebral reserve capacity, thus enabling them to express their disease later [49]. High-functioning patients seem able to delay the onset of symptoms, i.e., the onset of clinical disease. All epidemiological studies concur that the level of education and the nature of the professional activity are powerful determinants in the risk of developing the disease, at least at the statistical level [50]. Cognitive stimulation in the first years of life therefore plays an important role. It is indeed during this period of life that brain plasticity is the greatest. All babies have the same number of neurons at birth. A stimulating and benevolent environment will enable the establishment of abundant synaptic connections, neural capital that will be the source of optimal intellectual development and a guarantee of delaying, when the time comes, the expression of neurodegenerative diseases [49].

Conclusion

This mini review confirms that low or basic health education is consistently associated with worse self-perceived health, a shorter life expectancy and, unfortunately, a longer time spent with disability. These facts have their roots in the early childhood and family/life environment and are linked to inappropriate health behaviours, inadequate lifestyles, and poor acceptance of preventive measures (physical exercise, hygiene, healthy diet, and vaccines), as well as a poor ability to interpret health messages, and almost certainly, delayed consultation for medical diagnosis.

In this context, the lifelong educational trajectory appears as essential as the socio-economic status and life environment to better orient health promotion and targeted prevention. An educational approach makes it possible to enhance the understanding of the occurrence of age-related diseases and disability and provides an opportunity to adapt the communication level. More patients than doctors and health care professionals would imagine do not possess a sufficient basic level of health education to correctly understand explanations about disease and to assimilate diet and medication recommendations. There is a compelling need to use the reformulation technique to ensure that patients have correctly understood health explanations and messages.

The re-emergence of these educational health considerations prompts us to insist on the value of actions that raise the global education level of the whole population. The three most important groups to target are firstly children, their parents, and their teachers; secondly, the healthcare professionals whose knowledge is not updated enough, and whose communication techniques may be lacking. The third group to target is the ageing and old population, who could greatly benefit from health education training, since they are the ones, most concerned by these issues.

Acknowledgments

The authors of this paper would like to thank all contributors, the members of the French and Mexican Academies of Medicine who worked within the framework of the International Relations Committees of both Academies, for their inspiring contributions:

French Academy of Medicine*: Ardaillou R, Barthelemy C, Berche P, Bertrand D, Bioulac B, Bricaire F, Debre P, Dubois B, Goulle JP, Guerault C, Jaffiol Cl, Junien Cl, Komadja M, Michel JP, Parodi AL✝, Reach G, Spira A, Vuitton D, and Wemeau JL with moreover the expertise of Oppert JM and Waynberg J.

Academy of Medicine of Mexico**: Barriguete Melendez A*, Cordoba Villalobos JA*, Correa Rotter R, Fonseca Correa J, Garcia Garcia JE, Del Carmen Garcia Peña, Gutierrez Robledo LM*, Kaufer Horwitz M, Lazcano Ponce E, Linares Reyes CE, Lozano Juarez LR, Medina-Mora Icaza ME and Nicolini Sanchez JH. The authors thank Dr. Fiona Ecarnot from the University of Franche-Comté, Besançon, France for editing of the manuscript.

Conflict of Interest Statement

None of the authors have any conflict of interest in relation with this work and paper.

Funding Sources

None of the authors receive any funding for contributing to this work and the preparation of this paper.

Author Contributions

Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work: Jean-Pierre Michel, Luis Miguel Gutierrez Robledo, and André-Laurent Parodi. Drafting the first draft and revising it critically for intellectual content after comments of the co-authors: Emilia Frangos. Revision and submission of the revised version: Jean-Pierre Michel. Final approval of the revised version to be published: Emilia Frangos, Jean-Pierre Michel, Patrice Debré, and Jorge Armando Barriguete-Mélendez. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: Emilia Frangos, Jorge Armando Barriguete-Mélendez, Patrice Debré, Luis Miguel Gutiérrez Robledo, and Jean-Pierre Michel.

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