A top cardiovascular researcher is sounding the alarm over global heart health guidelines, warning that universal recommendations may not deliver the intended benefits.
Cardiovascular disease is the number one cause of death around the world, responsible for most lives lost each year. Strikingly, 80 percent of these deaths happen in low- and middle-income countries. Yet, the heart-health guidelines we rely on are mostly shaped by research from wealthier nations.
According to Scott Lear, a professor of health sciences at Simon Fraser University and the Pfizer/Heart & Stroke Foundation Chair in Cardiovascular Prevention Research, these guidelines often miss the deeper, underlying causes of heart disease that affect people globally.
“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,” says Lear, the lead author of a new review examining the impact of social, environmental, and policy factors on cardiovascular disease globally.
“There’s a stark contrast between a daily sidewalk 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 says. “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.”
Examining 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 over 212,000 participants from 28 nations across five continents.
Every three years, researchers collect a wide range of information. This includes detailed surveys and physical measurements like height, weight, blood pressure, waist-hip ratio, and lung capacity. They also gather additional information through specialized 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 health care.
About 87 per cent of PURE participants live in low- or middle-income countries, uniquely positioning the study to examine individual risk factors related to urbanization, says 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, self-reported physical activity was highest in high-income countries, despite over 22 per cent of participants sitting for more than eight hours a day. By contrast, only 4.4 per cent 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, explains 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,” says Lear. “For many of these farmers, getting the recommended minimum of five servings of fruits and vegetables a day would eat up 50 per cent of their household income.”
Reference: “Social factors, health policy, and environment: implications for cardiovascular disease across the globe” by Scott A Lear, Martin McKee, Perry Hystad, Blake Byron Walker, Adrianna Murphy, Michael Brauer, Marjan Walli-Attaei, Annika Rosengren, Sumathy Rangarajan, Clara K Chow and Salim Yusuf, 22 April 2025, European Heart Journal.
DOI: 10.1093/eurheartj/ehaf212
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4 Comments
“…, Lear’s review study identified several other causes behind the causes of CVD worldwide, including nutrition, education, tobacco use, air pollution, climate change, …”
While mentioned, it is not explained how climate change impacts CVD. It is as though “climate change” is added reflexively to any article covering negative subjects.
It may be true in cases when some areas experience severe weather changes. For example, people who used to live in cold conditions must now turn to much higher temperatures or vice versa, but I don’t know if 25-year research and set of data can show it. However, as you pointed out, it would be great if the role of these factors was explained in the article.
“…, consumption of fruits and vegetables is lower in low-income countries because farmers can’t afford to eat their own produce.”
In First-World countries, fruit that is bruised, over-ripe, misshapen, or damaged by birds is less saleable. If the farmers were to eat ripe fruit that wouldn’t make it to market without spoiling, or is unlikely to be sold because it is less than ideal, they could get more fruit and vegetables in their diet. Rather than feed the unsaleable fruits and vegetables to their livestock, they could cut out the good parts and eat that. It may be that they don’t understand the importance of fruits and vegetables to their diet.
Good point. In addition, the factor may be opposite in some cases: they knew that the pesticide level was exceeded and therefore did not eat it. Less likely but still possible in areas where there is no control of the process.