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
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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
Abstract

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.

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