A top cardiovascular disease expert from Simon Fraser University is raising concerns about global heart-health guidelines, arguing that they often fail to consider the realities faced by people in low- and middle-income countries.
Dr. Scott Lear, professor of health sciences and Chair in Cardiovascular Prevention Research, warns that recommendations designed in high-income countries may not be practical—or even possible—for much of the world’s population.
Cardiovascular disease (CVD) remains the world’s leading cause of death, with 80% of those deaths occurring in low- and middle-income countries.
Yet, the universal recommendations aimed at preventing it—such as 75 minutes of weekly exercise and five servings of fruits and vegetables per day—are largely based on data from wealthy nations. According to Dr. Lear, this creates a major disconnect between advice and reality.
“The world extends beyond high-income countries,” says Lear. “You can’t compare a peaceful daily walk in Vancouver to walking to work in New Delhi, where the air pollution is among the worst in the world, and many people lack access to clean public transport or even sidewalks.”
Lear’s review, recently published in a global health journal, draws on findings from the Prospective Urban Rural Epidemiology (PURE) study.
Launched in 2002, the PURE study is one of the most comprehensive global health studies ever conducted, with over 212,000 participants from 28 countries across five continents. It examines how factors like lifestyle, environment, healthcare access, and policy impact chronic illnesses, including heart disease.
Unlike many studies that focus on individuals’ habits, Lear’s work explores the broader “causes behind the causes” of heart disease—looking beyond exercise and diet to understand the social and environmental systems that shape health.
The review points to a wide range of global risk factors, including nutrition, air pollution, tobacco use, climate change, social isolation, and healthcare access. Lear emphasizes that these influences can vary not just between countries, but even between neighborhoods in the same city.
Not All Activity Counts the Same
Exercise is a well-known way to protect the heart, but how and why people move their bodies can vary dramatically. Lear’s analysis shows that people in low-income countries often perform physical labor out of necessity—walking long distances for work, doing heavy domestic tasks, or laboring in agriculture—yet still fall short of recommended “physical activity” guidelines.
Meanwhile, people in wealthy countries reported more activity on paper, mostly through planned workouts and gym visits. Even though 22% of people in high-income countries sat for more than eight hours a day, their structured exercise helped them meet activity goals.
In comparison, only 4.4% of people in low-income countries sat that long, but their unstructured physical work was often not enough to meet guidelines that focus on exercise intensity and duration.
The Cost of Healthy Eating
Healthy diets are another crucial part of preventing heart disease. Ideally, people should eat a variety of fruits, vegetables, legumes, nuts, fish, and dairy. But Lear found a major barrier for many in low-income areas: cost.
Even in rural farming communities, where fruits and vegetables are grown, families may not be able to afford to eat their own crops. “This was a real eye-opener,” says Lear. “In some low-income countries, eating five servings of fruits and vegetables a day could take up half of a household’s income.”
In both rich and poor countries, fruits and vegetables are easier to find and cheaper in cities than in rural areas. But in many parts of the world, urbanization also brings new problems—processed food becomes more available, traditional diets shift, and pollution levels rise, increasing heart disease risks.
A Call for Equity in Heart-Health Guidelines
Dr. Lear argues that it’s time to rethink what “universal” heart-health advice really means. The same guidance can’t be equally applied to a factory worker in Bangladesh, a single mother in rural Kenya, and a retiree in Canada.
Instead, global health organizations need to consider local realities—like air quality, food prices, transportation systems, and the nature of people’s daily work—when making recommendations.
“Heart-health policies must be rooted in real life,” says Lear. “To make a real impact, we have to recognize that health behaviors don’t happen in a vacuum. They’re shaped by economics, environment, and access.”
By shining a light on the inequalities that drive global heart disease, Lear hopes to inspire more inclusive health policies that take into account the everyday challenges millions face—and ultimately save more lives.
If you care about heart health, please read studies that yogurt may help lower the death risks in heart disease, and coconut sugar could help reduce artery stiffness.
For more information about health, please see recent studies that Vitamin D deficiency can increase heart disease risk, and results showing vitamin B6 linked to lower death risk in heart disease.
The research findings can be found in European Heart Journal.
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