Universal advice to “exercise more and eat your vegetables” may not be enough—or even realistic—for much of the world, according to a new study led by Simon Fraser University researcher Scott Lear.
Cardiovascular disease (CVD) is the leading cause of death globally, with 80% of related deaths occurring in low- and middle-income countries. Yet, international heart health recommendations are largely based on studies from high-income countries and may not reflect the lived realities of most of the world’s population.
Lear, a health sciences professor and the Pfizer/Heart & Stroke Foundation Chair in Cardiovascular Prevention Research, says these recommendations often fail to address the broader social, environmental, and economic factors that contribute to heart disease.
There’s a big difference between taking a walk in Vancouver’s West End and walking to work in New Delhi, where pollution is extreme, cars are unaffordable, and transit is limited,” Lear said. “We can’t treat the world as if it lives under the same conditions.”
Findings from the PURE Study
Lear’s review draws on data from the ongoing Prospective Urban Rural Epidemiology (PURE) study, which has tracked more than 212,000 participants in 28 countries since 2002. About 87% of those participants live in low- or middle-income countries, offering a rare global perspective on cardiovascular risk.
The study collects data every three years, including health measurements and surveys focused on CVD. It explores not just individual risk factors, but also broader influences like air pollution, education, access to health care, and climate change.
Exercise: Privilege or Necessity?
While lack of exercise is a well-known risk factor for heart disease, the study found major differences in how and why people move. In wealthier countries, more participants reported high physical activity—despite over 22% sitting for more than eight hours a day.
In contrast, in lower-income countries, only 4.4% reported sitting that long, yet their total activity was often lower. That’s because in those regions, exercise tends to come from work, chores, or transportation, not from structured leisure-time workouts.
When Farmers Can’t Afford Their Own Produce
Diet also plays a critical role in heart health, but access to healthy food is uneven. Fruits, vegetables, legumes, and other nutritious foods are more available and affordable in urban areas across all income levels.
However, Lear found that fruit and vegetable consumption was surprisingly lower in low-income countries. One reason: many farmers can’t afford to eat the food they grow.
These findings challenge the idea that healthy behaviors are simply about personal choice,” Lear said. “In many places, structural barriers prevent people from following standard health advice.”
Rethinking Global Health Strategies
The review highlights the need to shift global heart-health policies away from one-size-fits-all solutions. Instead, Lear recommends targeting the root causes of cardiovascular disease—such as poverty, pollution, and poor access to health care—and adapting strategies to local contexts.
He hopes the findings will encourage policymakers and public health leaders to design more inclusive and realistic approaches to improving heart health around the world.
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