With accelerating urbanization in low- and middle-income countries contributing to significant environmental and societal impacts on cardiovascular health, a State of the Art Review published April 22 in the European Heart Journal examines key findings from the Prospective Urban Rural Epidemiology (PURE) study and other research seeking to uncover the environmental, social and policy determinants of cardiovascular health in countries with various states of economic development and proposes key policy recommendations based on these results.

Beginning in 2002, the community-based cohort PURE study, including 28 countries with 212,299 participants from five continents, seeks to determine the impact of environmental and individual-level risk factors on cardiovascular disease as well as other noncommunicable diseases. In their review, Scott A. Lear, PhD, et al., outline a range of influential factors including physical activity environment, food environment, tobacco environment, education and economic factors, social isolation and cohesion, access to medications, treatment and health care systems, ambient and household air pollution, and climate change, diving into their effects on the risk of cardiovascular disease.

The authors note that of all the behavioral factors analyzed, tobacco use was the strongest predictor of cardiovascular disease followed by physical inactivity. They also highlight the effect that health policies on tobacco regulation and medication access and prices can have on issues like smoking rates and medication adherence, ultimately producing a significant impact on cardiovascular health. Availability and affordability of medications to manage conditions like diabetes and blood pressure were key in mitigating risk among PURE study participants.

Lear and colleagues also consider both the challenges and opportunities presented by current urbanization trends. While increasing air pollution may counteract potential benefits for physical activity, greater access to education, better medical care and treatments, and reduced household air pollution exposure are all likely positive effects from more urban communities.
"With economic development and social changes in [lower- and middle-income communities] happening rapidly, now is the time to translate the findings of PURE and similar studies into policy to ensure development is also seen through a health lens," write the authors.

Policy recommendations suggested by the authors include: incorporating global evidence into influential guidance documents, enhancing collaborations between researchers with diverse backgrounds, increasing multi-country studies with participants from diverse settings, prioritizing population-level measures to make healthy choices easier, viewing educational attainment as a social determinant of health, implementing adaptation strategies to act on climate change, and more.