**5. Conclusion**

The prevention and sensible management of cardiometabolic risk factors such as hypertension, obesity, dyslipidemia, and diabetes can markedly alter cardiovascular morbidity and mortality. Interestingly, cardiovascular risk is often associated with more than one cardiometabolic risk factor related to elevated cortisol levels. The metabolic syndrome describes this group of interrelated disorders such as insulin resistance, abdominal obesity, glucose intolerance, dyslipidemia, and hypertension [18]. HCC levels provide a measure of long-term exposure to chronic stress and have the potential as a suitable biomarker of CMR and contribute to the prevention, early diagnosis, treatment, and management of CVD. Hair cortisol measurements potentially reduce the variability associated with self-reported measures and provide a more robust view than the acute cortisol determinations in urine, saliva, and blood samples. While the evidence for the relationship between cardiometabolic risk and cortisol is clear and compelling, inconsistencies in the data must be addressed and understood.

A recent meta-analysis showed that adherence to several healthy lifestyle behaviors simultaneously reduced cardiovascular disease risk by 66% compared with adopting none or only one behavior [44]. However, no evidence exists that interventions that reduce cardiometabolic risk factors decrease hair cortisol levels in preventing or treating CVD [7]. More extensive studies are needed to ascertain the use of hair cortisol as an effective measure of stress reduction interventions. Also, further research is required to delineate whether HCC is a biomarker of CVD or CVD risk to utilize HCC in clinical settings effectively. Further insight into the mechanisms underlying increased cortisol exposure is necessary for the more effective implementation of cortisol-lowering therapies and potential new treatment targets.

## **Acknowledgements**

I express my sincere gratitude to Francina (Riah) Van Wyk and Momar Milliones for their continued support.

## **Conflict of interest**

The author declares no conflict of interest.
