Americans aren’t exactly known as the healthiest population in the world; more than one-third of the country is obese, thanks in part to oversized portions of food and lack of physical activity. What we’re eating isn’t much better than how much, either — 61 percent of our calories come from highly processed food, according to Time. While it may not have been a secret that the nation struggles with its health, a new study has concluded the problem is worse than previously thought.

Have a good diet, get moderate exercise, abstain from smoking, and maintain the recommended body fat percentage. These are the four basic parameters researchers from Oregon State University and the University of Mississippi believe constitute a “healthy lifestyle.” They also said doctors all over the world advise their patients about these markers. Yet, according to their research, only 2.7 percent of the United States adult population achieves all four.

“The behavior standards we were measuring for were pretty reasonable, not super high,” said Ellen Smit, senior study author and an associate professor in the OSU College of Public Health and Human Sciences, in a statement. “We weren’t looking for marathon runners.”

Failing to meet these standards is associated with a higher risk of cardiovascular disease, Type 2 diabetes, cancer, and several other health problems. Smit said the study results were not encouraging. “This is pretty low, to have so few people maintaining what we would consider a healthy lifestyle,” she said. “This is sort of mind boggling. There’s clearly a lot of room for improvement.”

In another striking statistic, a mere 10 percent of participants had a body fat percentage within the healthy range. The dangers of excess body fat, especially in the abdominal area, are well documented. Heart disease, metabolic syndrome, and cancer are associated with high levels of belly fat, and researchers have recently debunked the “fat but fit” mentality as bogus — even if an obese person regularly exercises, their risk of early death is still higher than a person of average weight.

Though the number of participants who met all four parameters was very low, more people met some of the criteria, but not all. Sixteen percent of adults met three of the guidelines, 37 percent met two, and 34 percent met one. Eleven percent of participants met none of the healthy lifestyle parameters.

The study was based on a large group — 4,745 people involved in the National Health and Nutrition Examination Survey — which makes the study more valuable than if it had used a small sample set. Many of the measurements were taken with biomarkers, like blood pressure, cholesterol, and sophisticated x-ray absorptiometry, a technique to measure body fat, rather than relying on a cruder measurement from height and weight (BMI).

Participants also wore an accelerometer to determine their levels of physical activity, and the subjects underwent blood testing to make sure they were nonsmokers if they claimed to be. Diet had to be self-reported, with participants recording their food consumption and researchers assessing who followed the United States Department of Agriculture’s food recommendations.

The researchers predicted that the more healthy lifestyle parameters a participant met, the better their cardiovascular biomarkers would look. They were correct; having three or four healthy lifestyle markers was associated with lower cholesterol and homocysteine (an amino acid linked to heart disease) levels compared to those meeting none of the parameters.

The researchers say more research is needed for public health officials to effectively increase healthy lifestyle characteristics in adults.

Source: Loprinzi P, Branscum A, Hanks J, Smit E. Healthy Lifestyle Characteristics and Their Joint Association With Cardiovascular Disease Biomarkers in US Adults. Mayo Clinic Proceedings. 2016.