Among patients with a coronary heart disease or stroke event from countries with varying income levels, the prevalence of healthy lifestyle behaviors (such as regular physical activity, eating a healthy diet, and not smoking) was low, with even lower levels in poorer countries, according to a study in the April 17 issue of JAMA.
"Observational data indicate that following an acute coronary syndrome, those who adhere to a healthier lifestyle have a lower risk of recurrent events. Smoking cessation is associated with a lower risk of death and myocardial infarction [heart attack], high-quality diets and regular exercise are associated with lower risk of death or recurrent cardiovascular disease events after a myocardial infarction. Thus, avoidance of smoking or its cessation, improving diet quality, and increasing physical activity level are recommended for secondary prevention of cardiovascular disease," according to background information in the article. "The proportion of the estimated 100 million individuals worldwide who have vascular disease in the community, especially from lower-income countries, living in rural areas, and who adopt healthy lifestyle behaviors is not known."
Koon Teo, M.B., Ph.D., of McMaster University, Hamilton, Ontario, Canada, and colleagues examined the prevalence of avoidance or cessation of smoking, eating a healthy diet, and undertaking regular physical activities by individuals with a coronary heart disease (CHD) or stroke event. The Prospective Urban Rural Epidemiology (PURE) was a large, prospective study that used an epidemiological survey of 153,996 adults, 35 to 70 years of age, from 628 urban and rural communities in 3 high-income countries (HIC), 7 upper-middle-income countries (UMIC), 3 lower-middle-income countries (LMIC), and 4 low-income countries (LIC), who were enrolled between January 2003 and December 2009. The main outcome measures for the study were smoking status (current, former, never), level of exercise (low, moderate, or high, as gauged by metabolic equivalent task [MET]-min/wk), and diet (classified by the Food Frequency Questionnaire and defined using the Alternative Healthy Eating Index).
Of the 153,996 enrolled participants, 7,519 (4.9 percent) had a CHD or stroke event. The median (midpoint) interval from event to study enrollment was 5.0 years for CHD and 4.0 years for stroke. Among the 7,519 individuals with self-reported CHD or stroke, 18.5 percent continued to smoke; 35.1 percent undertook high levels of work- or leisure-related physical activity, and 39.0 percent had healthy diets.
"Among the participants who had ever smoked, 52.5 percent had stopped smoking; the prevalence of smoking cessation was highest in the high-income countries (74.9 percent) and lowest in the low-income countries (38.1 percent), with graded decreases by decreasing country income status (56.5 percent in upper-middle-income countries and 42.6 percent in lower-middle-income countries)," the authors write. "Low-income countries had the lowest prevalence who had healthy diets (25.8 percent) compared with the prevalences in high-income countries (43.4 percent), upper-middle-income countries (45.1), and lower-middle-income countries (43.2 percent)."
The researchers add that overall, 14.3 percent of individuals did not have any of the 3 healthy lifestyle behaviors; 42.7 percent had only 1 healthy behavior, 30.6 percent had 2, and only 4.3 percent had all 3 healthy lifestyle behaviors.
Levels of physical activity increased with increasing country income but this trend was not statistically significant.
"These variations in lifestyle prevalence can provide insights into opportunities to enhance cardiovascular disease prevention through adopting healthy lifestyle behaviors," the authors write. "High-income countries had more comprehensive approaches to tobacco control (e.g., education on tobacco, smoking cessation programs, and active taxation and legislative measures), which likely account for the higher cessation rates."
"Our data indicate that the prevalence of following the 3 important healthy lifestyle behaviors was low in individuals after their CHD or stroke event. These patterns were observed worldwide but more so in poorer countries. This requires development of simple, effective, and low-cost strategies for secondary prevention that is applicable worldwide."
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