The United States is far from the healthiest nation in the world.

That award, according to Bloomberg, goes to Singapore, followed by Italy, and Australia.

The United States is in 33rd place between the Czech Republic and Bosnia and Herzegovina. It’s in 5th place in the Americas.

According to a new study, few Americans have a lifestyle that is considered healthy.

In fact, less than 3 percent of Americans meet the measurable characteristics that reduce a person’s risks for heart disease, according to new research published in the journal Mayo Clinic Proceedings.

Heart disease remains the number one cause of death in the United States. It contributes to one in four deaths and kills about 610,000 Americans every year, according to the U.S. Centers for Disease Control and Prevention (CDC).

The American Heart Association’s Strategic Impact Goal Through 2020 and Beyond focuses on four key ways to reduce heart disease in America: not smoking, reducing body mass index (BMI), getting adequate exercise, and eating a balanced diet.

According to the new Mayo Clinic report getting there is going to take some work.

Read More: Get the Facts on Heart Disease »

Three Years of Data

Researchers from the University of Mississippi, Oregon State University, and the University of Tennessee at Chattanooga used three years’ worth of data from the National Health and Nutrition Examination Survey, an ongoing series of studies the CDC conducts to test the health of the nation.

Participants in the study were subjected to objective standards to test the levels of their health, such as blood tests for smoking and X-rays to measure BMI.

Researchers found that only 2.7 percent of the 4,745 participants ages 20 to 85 met all four criteria to be considered for living a healthy lifestyle. Those included:

  • not smoking
  • eating a diet that aligns with nutritional guidelines
  • exercising at least 150 minutes a week, or 30 minutes five times a week.
  • keeping a BMI below 20 percent for men and 30 percent for women

Researchers also looked for the presence of biomarkers associated with an unhealthy lifestyle. These included blood pressure, cholesterol — both good and bad— fasting glucose, insulin resistance, and homocysteine levels.

Nearly 72 percent of those studied were nonsmokers, a big improvement over rates two decades ago. Also, about 47 percent were sufficiently active.

However, less than 38 percent consumed a healthy diet, and less than 10 percent had an acceptable BMI.

All combined, less than 3 percent met all four goals and 11 percent met none.

“We also show that having more healthy lifestyle characteristics is associated with more favorable biomarker levels that are related to various chronic diseases,” the study states. “Although multiple healthy lifestyle characteristics are important, specific healthy lifestyle characteristics may explain much of the variation for several of the biomarkers.”

Read More: How Smoking Increases Risk of Heart Disease »

Who’s Getting It Right

The most common combination was participants who didn’t smoke, had a healthy diet, and an active lifestyle.

Women were more likely than men to not smoke and eat healthy. They were, however, less likely to be active.

Compared with their younger counterparts, older adults were less likely to smoke and more likely to eat well, but they were also less active and had higher BMIs. People 20 to 39 years old had the highest rates of healthy lifestyles.

Mexican-Americans were more likely to consume a healthy diet. African-Americans had the fewest healthy lifestyle characteristics compared with non-Hispanic whites.

Overall, though, researchers found, there was little variation by age, sex, or ethnicity.

The study’s authors recommend more research into how to initiate strategies to improve the heart health of the nation.

“Although having multiple healthy lifestyle characteristics is important, specific health characteristics may be more important for particular cardiovascular disease risk factors,” the study concluded.

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