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

Download PACE.TEO JAMA april 2013.pptx



1. Chow CK, Jolly S, Rao-Melacini P et al. Association of diet, exercise, and smoking modification with risk of early cardiovascular events after acute coronary syndromes. Circulation. 2010; 121(6):750-758.
2. 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
3. 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;
4. Teo K, Chow CK, Vaz M et al. PURE Investigators-WritingGroup. 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, e1.
5. 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):1231-1243.
Find this article on Pubmed