Physicians' Academy for Cardiovascular Education

Prevalence of a healthy lifestyle after CHD or stroke is generally low

Literature - Teo K, Lear S, Islam S, et al. PURE Investigators - JAMA. 2013 Apr 17;309(15):1613-21. doi: 10.1001/jama.2013.3519

Prevalence of a healthy lifestyle among individuals with cardiovascular disease in high-, middle- and low-income countries: The Prospective Urban Rural Epidemiology (PURE) study.

Teo K, Lear S, Islam S, et al. PURE Investigators
JAMA. 2013 Apr 17;309(15):1613-21. doi: 10.1001/jama.2013.3519


Avoidance of smoking, a healthy diet and increased physical activity level are important factors in secondary prevention of cardiovascular disease. Yet, only small proportions of individuals followed recommended lifestyle practices after having suffered from a cardiovascular event [1-3].
This study examines the prevalence of the 3 healthy lifestyle behaviours at enrolment in individuals who have reported a coronary heart disease (CHD) or stroke event in the Prospective Urban Rural Epidemiology (PURE) study. The PURE study is a prospective cohort that includes 153996 participants from urban and rural communities in high-, middle-, and low-income countries [4,5].

Main results

  • In high-income countries cessation of smoking was highest (74.9%, 95%CI: 71.1-78.6), while it was lowest in low-income countries (38.1%, 95%CI: 33.1-43.2), and graded decreases by decreasing country income status of upper- and lower-middle-income countries (P<0.001 for trend). At each level of country income, similar decreasing trends were seen for smoking cessation prevalence with decreasing level of education.
  • 25.5% (95%CI: 16.7-36.6) of participants in low-income countries undertook high levels (>3000 MET minutes/week) of work- or leisure-related physical activities, 41.5% (95%CI: 33.1-50.4) in lower-middle-income countries, 29.9% (95%CI:22.2-38.9) in upper-middle-income countries and 45.2% (95%CI: 29.8-61.5) in high-income countries (no significant trend).
  • Using a modified AHEI score (alternative healthy eating index), 25.8% (95%CI:13.0-44.8) of participants in low-income countries consumed a healthy diet, as compared to 43.4% (95%CI:21.0-68.7) in high-income countries, 45.1% (95%CI:30.9-60.1) in upper-middle-income countries and 43.2% (95%CI:30.0-57.4) in lower-middle-income countries. Increasing levels of education were associated with graded increases in consumption of healthy diets in all types of countries.
  • As compared to participants from low-income countries, individuals were more likely to have two or more healthy lifestyle behaviours if they were from a high-income country (OR: 2.61, 95%CI: 2.11-3.22), an upper-middle-income country (OR: 1.42, 95%CI:1.118-1.70) or a lower-middle-income country (OR: 2.70, 95%CI: 2.33-3.13).
  • Urban residents were more likely to have 2 or more healthy lifestyles than individuals living in rural areas (OR: 1.22, 95%CI: 1.11-1.34, P<0.001). Men more often did not have any healthy lifestyle behaviour (26.4%, 95%CI: 22.1-31.1) than women (7.2%, 95%CI: 5.7-9.0, P<0.01), and more women had 3 healthy behaviours (7.4%, 95%CI: 5.4-10.0) than men (2.4%, 95%CI: 1.7-3.4, P<0.001). Sex differences were consistent across country income status, country or region.


A large gap exists globally between actual and ideal participation in the three key lifestyle behaviours after a CHD or stroke event. Overall, individuals from higher income countries had a higher prevalence of healthy lifestyle behaviours. Higher education was also associated with a healthy lifestyle, although it showed a less consistent pattern. These prevalences can provide insight into opportunities to improve CV disease prevention, by targeting education, taxation and legislative measures where it is most needed

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