A leading international cardiovascular researcher has warned that global heart health guidelines – and universal recommendations – may not deliver the intended benefits, and often miss deeper underlying causes of heart disease.
Cardiovascular disease is the number one cause of death around the world, responsible for most lives lost each year. Yet while 80% of these deaths happen in low- and middle-income countries, the heart-health guidelines on which we rely are mostly shaped by research from wealthier nations.
Scott Lear, a Professor of Health Sciences at Simon Fraser University in Canada, and the Pfizer/Heart & Stroke Foundation Chair in Cardiovascular Prevention Research, said the world “extends beyond high-income countries when we think about universal recommendations like 75 minutes of exercise each week or getting five servings of fruit and vegetables every day”.
Lear is the lead author of a recent review examining the impact of social, environmental, and policy factors on cardiovascular disease globally.
“There’s a stark contrast between a daily side-walk stroll in Vancouver’s West End and walking to work in New Delhi, the world’s most polluted city, where many people cannot afford to drive and public transit is lacking,” he said.
“We cannot assume that life is the same everywhere. The environments in which people live and the kind of work they do makes a huge difference to their health.”
The causes behind the causes
The new review takes a deeper look at what drives heart disease by exploring the “causes behind the causes”. It draws on findings from the Prospective Urban Rural Epidemiology (PURE) study, a global research effort that has been tracking health trends since 2002.
The PURE study gathers data from people living in high-, middle-, and low-income countries, covering more than 212 000 participants from 28 nations across five continents.
Every three years, researchers collect a wide range of information, which includes detailed surveys and physical measurements like height, weight, blood pressure, waist-hip ratio, and lung capacity. They also gather additional information through specialised questionnaires focused on heart health and other key areas.
In addition to physical activity environments, Lear’s review study identified several other causes behind the causes of CVD worldwide, including nutrition, education, tobacco use, air pollution, climate change, social isolation and access to medication, treatment and healthcare.
About 87% of PURE participants live in low- or middle-income countries, uniquely positioning the study to examine individual risk factors related to urbanisation, said Lear. Although these review findings are based on global data, they also reflect the microcosms of different regions within a single city, or region.
Privilege shapes exercise
Lack of exercise is a major risk factor for cardiovascular disease, but the type and context of physical activity people do get also plays a role.
According to Lear’s review, published in the European Heart Journal, self-reported physical activity was highest in high-income countries, despite more than 22% of participants sitting for more than eight hours a day.
By contrast, only 4.4% of participants in low-income countries reported sitting for more than eight hours a day, yet their overall physical activity levels were lower.
The difference lies in the nature of the activity. In low-income countries, physical activity is often tied to work, transportation, and domestic tasks rather than leisure, explained Lear.
Priced out of produce
A healthy diet containing fruits, vegetables, legumes, nuts, fish and dairy can reduce the risk of cardiovascular disease. Lear reported that regardless of country income, fruits and vegetables were more readily available and more affordable in urban areas.
But he was also surprised to find that consumption of fruits and vegetables is lower in low-income countries because farmers can’t afford to eat their own produce.
“This is a real eye opener,” said Lear. “For many of these farmers, getting the recommended minimum of five servings of fruits and vegetables a day would eat up 50% of their household income.”
Study details
Social factors, health policy, and environment: implications for cardiovascular disease across the globe
Scott Lear, Martin McKee, Perry Hystad, Blake Byron Walker, Adrianna Murphy, Michael Brauer, Marjan Walli-Attaei, Annika Rosengren, Sumathy Rangarajan, Clara Chow and Salim Yusuf.
Published in European Heart Journal on 22 April 2025
Abstract
Cardiovascular disease (CVD) is the leading cause of deaths worldwide, with 80% occurring in low- and middle-income countries. These countries are characterised by rapid urbanisation, poorly funded health systems, poor access to prevention and treatment strategies, and increasing age and a higher prevalence of chronic disease. Rapid urbanisation has contributed to the significant environmental and societal changes affecting daily life habits and cardiovascular health. There is growing awareness that environmental and social exposures and policies can influence CVD directly or through behavioural risk factors. However, much of this knowledge comes from studies in high-income countries and is applied to low- and middle-income countries without evidence to indicate this is appropriate. This state-of-the-art review will present and synthesise key findings from the Prospective Urban Rural Epidemiology study and related studies that have aimed to understand the environmental, social, and policy determinants of cardiovascular health in countries across varying levels of economic development through an urban/rural lens. Emerging from these findings are future policy and research recommendations to accelerate the reduction of the global burden of CVD.
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