Global heart health recommendations may not serve the very populations most affected by the disease.
Cardiovascular disease (CVD) remains the leading cause of death worldwide, with 80% of deaths occurring in low- and middle-income countries. Yet, most international guidelines for heart health are based on studies conducted in high-income nations.
When universal targets like 75 minutes of exercise per week or five daily servings of fruits and vegetables are promoted, it is important to recognise that the world extends far beyond high-income countries, as highlighted in a new review exploring how social, environmental, and policy factors shape cardiovascular health globally.
There’s a world of difference between a brisk walk through Vancouver’s West End and a commute on foot through New Delhi, one of the world’s most polluted cities, where public transit is limited and many people can’t afford a car. It is not logical to pretend that health advice applies equally everywhere. Local environments and the kind of work people do have a profound impact on health outcomes.
The review draws on findings from the Prospective Urban Rural Epidemiology (PURE) study, a long-term global collaboration that has tracked more than 212,000 participants from 28 countries across five continents since 2002. The study collects data every three years, including physical measurements, core surveys, and supplemental questionnaires focused on CVD and related issues.
The review highlights a range of upstream factors that influence CVD risk across populations. These include not just physical activity and diet but also air pollution, climate change, social isolation, access to health care, education, tobacco use, and availability of medication. 87% of PURE participants live in low- or middle-income countries, offering a unique lens into how individual risk factors play out in rapidly urbanising contexts. These global patterns are often mirrored within the microcosms of a single city or region.
While insufficient physical activity is a known risk factor for heart disease, the context of that activity also matters. The review found that people in high-income countries reported the highest levels of physical activity, even though more than 22% spent over eight hours a day sitting. In contrast, only 4.4% of participants in low-income countries reported sitting that long, yet their overall activity levels were lower. The key difference? In low-income settings, physical activity is often tied to manual labour, transportation, or domestic work, not recreational exercise.
A heart-healthy diet rich in fruits, vegetables, legumes, nuts, fish, and dairy can help prevent cardiovascular disease. The review revealed that fruits and vegetables tend to be more available and affordable in urban centres, regardless of a country’s income level. Yet, in low-income countries, consumption remains low, not due to availability but affordability. In low-income regions, meeting the global standard of five servings of fruits and vegetables a day would consume up to half of the household income.
This review provides critical insights. In order to improve heart health around the world, strategies must reflect the realities people face in their daily lives.
Source: Simon Fraser University
Image Credit: iStock
References:
Lear SA, McKee M, Hystad P et al. (2025) Social factors, health policy, and environment: implications for cardiovascular disease across the globe. European Heart Journal.
