Lifestyle modifications vary based on socioeconomic status in cardiovascular patients (PURE Study)

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1. Smoking cessation, exercise, and healthy diet are widely recommended but variably adopted in patients with cardiovascular disease.

2. In a multi-national study, the authors demonstrate this variation to be dependent on national and individual socioeconomic status. 

3.  The likelihood of participants quitting smoking was significantly correlated with nationwide income level, regardless of participant education level.

Evidence Rating Level: 2 (Good) 

Study Rundown: In the present study, the authors seek to broaden the current understanding of health behavior in response to diagnosed cardiovascular disease in well-developed nations.  They examined three widely recommended behaviors for lifestyle modification following cardiovascular disease that are known to reduce risk but are often not adopted or poorly maintained in patients following a first cardiovascular event or diagnosis.  Their findings demonstrate, for the first time, a global gap in adoption of certain lifestyle modifications that is dependent on both national socioeconomic status and, in some cases, individual education level.

The most glaring limitation of the study is the dependence on patient self-reporting to establish diagnosis of cardiovascular disease, likely a necessary concession given the difficulty of gathering medical record information from widely varying systems in each of the chosen countries.  Using this approach, the authors were unable to verify the presence of cardiovascular disease in these patients or to stratify cases by disease type or severity.  In fact, in a sample of 455 patients, the authors found patient reports to be consistent with medical records in only 89% of cases.  Despite this limitation, the authors provide the first large-scale prospective examination of health behavior modification in response to cardiovascular disease, underscoring the importance of broadening the current discourse on the issue to a global perspective.

Click to read the study, published today in JAMA 

Relevant Reading: Association of psychosocial risk factors with risk of acute myocardial infarction in 11119 cases and 13648 controls from 52 countries (the INTERHEART study): case-control study.

In-Depth [prospective study]: The authors recruited 153,996 adults with a history of cardiovascular disease (coronary artery disease, diabetes, hypertension, or stroke) from urban and rural communities in seventeen countries with a wide range of income levels.  Participants were assessed for smoking status, physical activity level, and content of diet.  7,519 participants (4.9%) reported cardiovascular disease.  Of these, 52.5% of former smokers quit smoking, 35.1% engaged in high levels of physical activity, and 39% ate healthy diets according to the Alternative Healthy Eating Index, which has been shown to predict cardiovascular disease.  The likelihood of participants quitting smoking was significantly correlated with nationwide income level, regardless of participant education level (p=0.001-0.02).  In contrast, patients from high- and lower-middle-income countries were more likely to engage in high levels of physical activity, but only in patients with high school or equivalent degrees and beyond (p=0.001-0.007).  Finally, no significant differences were found in healthy eating between countries, regardless of education level.

By Jeff Dewey and Rif Rahman

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