Prevalence of a Healthy Lifestyle Among Individuals With Cardiovascular Disease in High-, Middle- and Low-Income Countries: The Prospective Urban Rural Epidemiology (PURE) Study

Study Questions:

What is the prevalence of lifestyle modification among adults with a history of coronary heart disease (CHD) or stroke from countries with differing economic profiles?


Data for this analysis were from the PURE (Urban Rural Epidemiology) study, a large, prospective cohort study that used an epidemiological survey of 153,996 adults, ages 35-70 years, from 628 urban and rural communities in three high-income countries (HIC), seven upper-middle-income countries (UMIC), three lower-middle-income countries (LMIC), and four low-income countries (LIC), who were enrolled between January 2003 and December 2009. The primary outcome measures were smoking status (current, former, never), level of exercise (low, <600 metabolic equivalent task [MET]-min/wk; moderate, 600-3000 MET-min/wk; high, >3000 MET-min/wk), and diet (classified by the Food Frequency Questionnaire and defined using the Alternative Healthy Eating Index).


Among 7,519 individuals with self-reported CHD (past event: median, 5.0 years ago) or stroke (past event: median 4.0 years ago), 18.5% (95% CI, 17.6%-19.4%) continued to smoke; only 35.1% (95% CI, 29.6%-41.0%) undertook high levels of work- or leisure-related physical activity, and 39.0% (95% CI, 30.0%-48.7%) had healthy diets. Those who did not undertake any of the three healthy lifestyle behaviors comprised 14.3% (95% CI, 11.7%-17.3%) of the study sample; 4.3% (95% CI, 3.1%-5.8%) had all three lifestyle behaviors. Overall, 52.5% (95% CI, 50.7%-54.3%) quit smoking, which included 74.9% (95% CI, 71.1%-78.6%) in HIC, 56.5% (95% CI, 53.4%-58.6%) in UMIC, 42.6% (95% CI, 39.6%-45.6%) in LMIC, and 38.1% (95% CI, 33.1%-43.2%) in LIC. Levels of physical activity increased with increasing country income, but this trend was not statistically significant. The lowest prevalence of eating healthy diets was in LIC (25.8%; 95% CI, 13.0%-44.8%) compared with LMIC (43.2%; 95% CI, 30.0%-57.4%), UMIC (45.1%; 95% CI, 30.9%-60.1%), and HIC (43.4%; 95% CI, 21.0%- 68.7%).


The investigators concluded that among a sample of patients with a history of prior CHD or stroke from countries with varying income levels, the prevalence of healthy lifestyle behaviors was low, with even lower levels in poorer countries.


These data suggest low prevalence rates for adoption of healthy lifestyles after cardiovascular events, and highlight significant gaps between countries by income status. Lifestyle factors including smoking cessation, healthy diet, and regular physical activity are associated with significant prevention benefits. Thus, these data have important global health policy implications.

Keywords: Coronary Artery Disease, Stroke, Life Style, Global Health, Exercise, Income, Coronary Disease, Smoking, Health Behavior, Prevalence, Rural Population, Tobacco, Developed Countries, Leisure Activities, Cardiovascular Diseases, Motor Activity, Diet, Smoking Cessation

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