Prevalence of a Healthy Lifestyle Among Individuals With Cardiovascular Disease in High-, Middle- and Low-Income Countries: The Prospective Urban Rural Epidemiology (PURE) Study | Cardiology | JAMA | JAMA Network
[Skip to Navigation]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address Please contact the publisher to request reinstatement.
Yusuf S, Hawken S, Ounpuu S,  et al;  INTERHEART Study Investigators.  Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study.  Lancet. 2004;364(9438):937-95215364185PubMedGoogle ScholarCrossref
O’Donnell MJ, Xavier D, Liu L,  et al;  INTERSTROKE Investigators.  Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study.  Lancet. 2010;376(9735):112-12320561675PubMedGoogle ScholarCrossref
Chow CK, Jolly S, Rao-Melacini P, Fox KA, Anand SS, Yusuf S. Association of diet, exercise, and smoking modification with risk of early cardiovascular events after acute coronary syndromes.  Circulation. 2010;121(6):750-75820124123PubMedGoogle ScholarCrossref
Iqbal R, Anand S, Ounpuu S,  et al; INTERHEART Study Investigators.  Dietary patterns and the risk of acute myocardial infarction in 52 countries: results of the INTERHEART study.  Circulation. 2008;118(19):1929-193718936332PubMedGoogle ScholarCrossref
Yusuf S, Reddy S, Ounpuu S, Anand S. Global burden of cardiovascular diseases, part I: general considerations, the epidemiologic transition, risk factors, and impact of urbanization.  Circulation. 2001;104(22):2746-275311723030PubMedGoogle ScholarCrossref
EUROASPIRE II Study Group.  Lifestyle and risk factor management and use of drug therapies in coronary patients from 15 countries: principal results from EUROASPIRE II Euro Heart Survey Programme.  Eur Heart J. 2001;22(7):554-57211259143PubMedGoogle ScholarCrossref
Teo K, Chow CK, Vaz M, Rangarajan S, Yusuf S.PURE Investigators-Writing Group.  The Prospective Urban Rural Epidemiology (PURE) study: examining the impact of societal influences on chronic noncommunicable diseases in low-, middle-, and high-income countries.  Am Heart J. 2009;158(1):1-7, e119540385PubMedGoogle ScholarCrossref
Yusuf S, Islam S, Chow CK,  et al; Prospective Urban Rural Epidemiology (PURE) Study Investigators.  Use of secondary prevention drugs for cardiovascular disease in the community in high-income, middle-income, and low-income countries (the PURE Study): a prospective epidemiological survey.  Lancet. 2011;378(9798):1231-124321872920PubMedGoogle ScholarCrossref
World Bank.  How do we classify countries? Accessed May 19, 2011
MacQueen KM, McLellan E, Metzger DS,  et al.  What is community? an evidence-based definition for participatory public health.  Am J Public Health. 2001;91(12):1929-193811726368PubMedGoogle ScholarCrossref
International Physical Activity Questionnaire (IPAQ).  Guidelines for data processing and analysis of the International Physical Activity Questionnaire (IPAQ)—short and long forms. Accessibility verified March 15, 2013
Kelemen LE, Anand SS, Vuksan V,  et al; SHARE Investigators.  Development and evaluation of cultural food frequency questionnaires for South Asians, Chinese, and Europeans in North America.  J Am Diet Assoc. 2003;103(9):1178-118412963948PubMedGoogle ScholarCrossref
Bharathi AV, Kurpad AV, Thomas T, Yusuf S, Saraswathi G, Vaz M. Development of food frequency questionnaires and a nutrient database for the Prospective Urban and Rural Epidemiological (PURE) pilot study in South India: methodological issues.  Asia Pac J Clin Nutr. 2008;17(1):178-18518364343PubMedGoogle Scholar
Dehghan M, Ilow R, Zatonska K,  et al.  Development, reproducibility and validity of the food frequency questionnaire in the Poland arm of the Prospective Urban and Rural Epidemiological (PURE) study.  J Hum Nutr Diet. 2012;25(3):225-23222390143PubMedGoogle ScholarCrossref
Dehghan M, Al Hamad N, Yusufali A, Nusrath F, Yusuf S, Merchant AT. Development of a semi-quantitative food frequency questionnaire for use in United Arab Emirates and Kuwait based on local foods.  Nutr J. 2005;4:1815921524PubMedGoogle ScholarCrossref
Dehghan M, Lopez JP, Duenas R,  et al.  Development and validation of a quantitative food frequency questionnaire among rural- and urban-dwelling adults in Colombia.  J Nutr Educ Behav. 2012;44(6):609-61321737352PubMedGoogle ScholarCrossref
Merchant AT, Dehghan M, Chifamba J, Terera G, Yusuf S. Nutrient estimation from an FFQ developed for a Black Zimbabwean population.  Nutr J. 2005;4:3716351722PubMedGoogle ScholarCrossref
Teo KK, Ounpuu S, Hawken S,  et al; INTERHEART Study Investigators.  Tobacco use and risk of myocardial infarction in 52 countries in the INTERHEART study: a case-control study.  Lancet. 2006;368(9536):647-65816920470PubMedGoogle ScholarCrossref
McCullough ML, Feskanich D, Stampfer MJ,  et al.  Diet quality and major chronic disease risk in men and women: moving toward improved dietary guidance.  Am J Clin Nutr. 2002;76(6):1261-127112450892PubMedGoogle Scholar
McCullough ML, Willett WC. Evaluating adherence to recommended diets in adults: the Alternate Healthy Eating Index.  Public Health Nutr. 2006;9(1A):152-15716512963PubMedGoogle ScholarCrossref
Dehghan M, Mente A, Teo KK,  et al; Ongoing Telmisartan Alone and in Combination With Ramipril Global End Point Trial (ONTARGET)/Telmisartan Randomized Assessment Study in ACEI Intolerant Subjects With Cardiovascular Disease (TRANSCEND) Trial Investigators.  Relationship between healthy diet and risk of cardiovascular disease among patients on drug therapies for secondary prevention: a prospective cohort study of 31 546 high-risk individuals from 40 countries.  Circulation. 2012;126(23):2705-271223212996PubMedGoogle ScholarCrossref
Kumra V, Markoff BA. Who's smoking now? The epidemiology of tobacco use in the United States and abroad.  Clin Chest Med. 2000;21(1):1-9, vii10763086PubMedGoogle ScholarCrossref
Taylor RS, Brown A, Ebrahim S,  et al.  Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials.  Am J Med. 2004;116(10):682-69215121495PubMedGoogle ScholarCrossref
Mendis S, Abegunde D, Yusuf S,  et al.  WHO study on prevention of recurrences of myocardial infarction and stroke (WHO-PREMISE).  Bull World Health Organ. 2005;83(11):820-82916302038PubMedGoogle Scholar
Original Contribution
April 17, 2013

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

Author Affiliations

Author Affiliations: Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada (Drs Teo, Dehghan, and Yusuf, Mr Islam, and Ms Rangarajan); Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Vancouver, British Columbia, Canada (Dr Lear); Providence Health Care, Vancouver, British Columbia, Canada (Dr Lear); St John's Medical College and Research Institute, Bangalore, India (Dr Mony); National Center for Cardiovascular Diseases, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China (Dr W. Li); Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (Dr Rosengren); Desarrollo e Innovacion Tecnologica, Clinica de Sindrome Metabolico, Prediabetes y Diabetes y Fundacion Oftalmologica de Sandander, Santander, Colombia (Dr Lopez-Jaramillo); Estudios Clinicos, Latinoamerica ECLA, Rosario, Santa Fe, Argentina (Dr Diaz); Dante Pazzanese Institute of Cardiology, Sao Paulo, Brazil (Dr Oliveira); Faculty of Medicine, Universiti Teknologi MARA, Sungai Boloh, Malaysia (Dr Miskan); Department of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan (Dr Iqbal); Department of Food Sciences and Dietetics, Wroclaw Medical University, Wroclaw, Poland (Dr Ilow); School of Public Health, University of Western Cape, Cape Town, South Africa (Dr Puone); Isfahan Cardiovascular Research Center, Isfahan University of Medical Sciences, Isfahan, Iran (Dr Bahonar); Cardiology Department, Ankara University, Ankara, Turkey (Dr Gulec); Family Medicine Department, Dubai Medical College, Dubai, United Arab Emirates (Dr Darwish); Universidad de La Frontera, Temuco, Chile (Dr Lanas); Health Action by People, Trivandrum, India (Dr Vijaykumar); Independent University Bangladesh, Dhaka (Dr Rahman); Department of Physiology, College of Health Sciences, University of Zimbabwe, Harare (Mr Chifamba); Beilingbridge Community Health Service Center, Taiyuan, Shanxi Province, China (Mr Hou); and Qingshanhu Community Health Service Station, Nanchang, Jiangxi Province, China (Dr N. Li).

JAMA. 2013;309(15):1613-1621. doi:10.1001/jama.2013.3519

Importance Little is known about adoption of healthy lifestyle behaviors among individuals with a coronary heart disease (CHD) or stroke event in communities across a range of countries worldwide.

Objective To examine the prevalence of avoidance or cessation of smoking, eating a healthy diet, and undertaking regular physical activities by individuals with a CHD or stroke event.

Design, Setting, and Participants Prospective Urban Rural Epidemiology (PURE) was a large, prospective cohort study that used an epidemiological survey of 153 996 adults, aged 35 to 70 years, from 628 urban and rural communities in 3 high-income countries (HIC), 7 upper-middle-income countries (UMIC), 3 lower-middle-income countries (LMIC), and 4 low-income countries (LIC), who were enrolled between January 2003 and December 2009.

Main Outcome Measures 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).

Results Among 7519 individuals with self-reported CHD (past event: median, 5.0 [interquartile range {IQR}, 2.0-10.0] years ago) or stroke (past event: median, 4.0 [IQR, 2.0-8.0] 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; 14.3% (95% CI, 11.7%-17.3%) did not undertake any of the 3 healthy lifestyle behaviors and 4.3% (95% CI, 3.1%-5.8%) had all 3. Overall, 52.5% (95% CI, 50.7%-54.3%) quit smoking (by income country classification: 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%).

Conclusion and Relevance Among a sample of patients with a CHD or stroke event from countries with varying income levels, the prevalence of healthy lifestyle behaviors was low, with even lower levels in poorer countries.