Dr Lingaraj Nath, Consultant Interventional Cardiologist, AMRI Bhubaneswar, Odisha, gives an insight about the seriousness of cardio vascular disease among the Indian youth
Biswanath, a 39-year-old government employee in district level centre, was in a normal daily routine at his office when he had sweating and chest heaviness. He felt very comfortable and visited the local doctor for an opinion. After doing an electrocardiogram, he was referred to a hospital in Bhubaneswar. A detailed evaluation diagnosed him with coronary artery disease (CAD), blockage of blood circulation in the heart. He had to undergo angioplasty surgery. Sedentary lifestyle and occasional smoking habit was blamed by the treating cardiologist as the cause of his heart problem at an early age.
For Sunita, a 44-year-old housewife, an even bigger surprise was in store. One day while in the kitchen, she felt dizzy which led to vomiting and she fainted. She visited the cardiac centre where she was diagnosed as having a heart attack. She stayed in the intensive care unit for four days and underwent an open bypass heart surgery. She had high blood pressure and cholesterol problem. Even after being told by her doctor about obesity issues, she didn’t pay heed to it.
Sunita and Biswanath are among a growing number of young people who have suffered life-threatening heart diseases. Heart attacks were once only associated with people in their late 50s and 60s. Recently, more people in their 20s, 30s and 40s have been getting heart ailments. The problem is that heart disease at a prime age takes away the productive years from young India. Socio-economic burden on person, family as well as nation is very high.
Recently, a Delhi-based fashion designer was admitted to a hospital in Delhi with heart ailments. Also, a national level cricket player in Mumbai had chest pain while driving his car, who was only 41. He had his angioplasty done for his heart problems. A research article published recently focused that Indians living abroad had higher incidence of heart disease compared with the people of the country where they migrated. Not only that, the seriousness of disease at a young age and duration of the hospital stay was also longer in NRI population.
India has the highest burden of CVDs (cardiovascular disease). The effects of CVD is felt on the productive workforce from 35–65 years. The incidence of CAD in young population has been reported to be 12 to 16 per cent in Indians. Half of the CVD-related deaths (i.e. 52 per cent of CVDs) in India occur below the age of 50 years and about 25 per cent of acute myocardial infarction (MI) in India occurs under the age of 40 years. This percentage is higher than most ethnic groups including Chinese, Japanese ,Americans and Europeans.
Heart diseases among the Indians occur five to 10 years earlier than in other populations around the world. According to the INTERHEART study, the median age for first presentation of acute MI in the South Asian (Bangladesh, India, Nepal, Pakistan, Sri Lanka) population is 53 years, whereas that in Western Europe, China, and Hong Kong is 63 years.
One reason why CVD is feared is that the problem often comes suddenly without warning. If timely diagnosis and treatment is not given it may prove fatal. Diagnostic facilities and treatment of cardiovascular disease is often not found in smaller towns and district level and when such patients are brought to referral centres precious time is lost.
CAD has been known to be a disease in which multiple factors like smoking, high cholesterol, high blood pressure, diabetes, central obesity and hereditary factors play a major role. Smoking has been shown to be a major dominant modifiable risk factor associated with young CAD. It has been observed that health awareness campaigns in the developed world have resulted in a decline in smoking and it has become socially less acceptable than it was a decade ago. In contrast, developing countries like China and India are witnessing an increase in the incidence of smoking, especially among adolescents and a rise in the use of smokeless tobacco like gutkha etc. even many advertisements in print and electronic media indirectly tries to portray smoking as fashionable. Bollywood movies which have a big cultural impact on the youth also conveys the same message. Greater efforts are required to control smoking among the young.
Lack of any effective exercise and sedentary lifestyle in young age group of 25 to 39 years is a well-known fact in India. With the advent of television and later Internet, traditional modes of relaxation like going out with friends for a walk or sports are less common now. Lack of open space for playing, cycling or recreation in most urban centres is only adding to the problems. Most of our school curriculum also has very little emphasis on sports or physical activity. Minimum requirement of exercise as per guidelines is 35-45 minutes a day for four to five days a week to fulfil the requirement of heart and vital organs.
The importance of dyslipidaemia (high cholesterol level in blood) as the cause of CAD is well known. Elevated levels of cholesterol, LDL-C and triglycerides have been found in young Indian subjects with CAD and been postulated to be of particular importance even in the younger variant of the disease. High triglyceride and low HDL(Good Cholesterol) levels are more of a universal phenomenon in Indian population. With rapid urbanisation and industrialisation, a nutritional transition is occurring in India. Continual increase in the prevalence of obesity is being seen.
With the introduction of an era of refined foods, including refined flour (maida), sugar, and hydrogenated oils, the traditional high complex carbohydrate, high fibre, low-fat diet has been replaced by a diet rich in fats and readily absorbable simple sugars and low in minerals and dietary fibres, a scenario threatening to produce similar health hazards to those seen in well developed nations. It is, however, important to emphasise that this nutritional transition is not inevitable.
Public health professionals need to develop strategies so that a healthier transition occurs. It is well known that controlling the risk factors in patients with CAD risk equivalent is effective in reducing the rates of CAD. The benefits of addressing the root cause of CVD, such as smoking, threatening levels of body fat, cholesterol, and blood pressure, and low intake of fruits and vegetables, together with the use of affordable and accessible preventive combination medications will be immense in a country the size of India in terms of number of lives saved, mostly among middle-aged persons.
The barriers to bringing about community and individual behavioural changes also need to be addressed. These findings may then be translated into an innovative preventive approach targeting both the community and individuals to help reduce the risk of CAD. Simple solutions to seemingly complex problems may be available within the community. For example, low intake of fruits and vegetables may be related to low availability and affordability, which may be solved by regular or weekly neighbourhood markets where farmers can sell their fresh produce themselves at a reasonable price; religious groups can help in promoting exercise, abstinence from smoking, and observance of a vegetarian diet; healthier ways of cooking traditional food can be demonstrated by local television stations, etc. Empowering the community to determine what works best for them may make a difference as far as CAD prevention is concerned.
While the mortality and morbidity from CAD has been falling in the western world, it has been climbing to an epidemic proportion among the Indian population and the youth in particular. Various factors that are thought to contribute to this rising epidemic include urbanisation of rural areas, large-scale migration of rural population to urban areas, increase in sedentary lifestyle, abdominal obesity, metabolic syndrome, diabetes, inadequate consumption of fruits and vegetables, increased use of fried, processed and fast foods, tobacco abuse. It is a matter of utmost concern that the Indian youth is under the grip of cardiovascular disease or its related cause factors. Even more worrisome is the fact that most young people are blissfully unaware of the seriousness of the issue.