Prof Sundeep Mishra
Department of Cardiology, AIIMS, New Delhi
Cerebrovascular diseases (including heart diseases) are number one killer worldwide, the number far exceeding infectious diseases, accidents, wars or even cancer. The disease is the number 1 killer even in developing countries now. It is also an important cause of death in the young population especially in the Indian sub-continent. However, this disease unlike infectious diseases does not have one cause (etiology), rather it has a group of risk factors as its causative complex. These risk factors include smoking, abnormal lipid values (cholesterol & its sub-fractions, triglyceride etc), diabetes, hypertension (high blood pressure), obesity (fatness), reduced physical activity, stress and abnormal genetics. Women seem to be naturally protected from this ailment in their reproductive age-group (generally considered between 15-45 years) because of reproductive hormones. However, once they achieve meno-pause, they are at as much risk as men of their age group.
South Asians represent approximately ¼ of the world's population – yet they account for nearly 2/3 of the world's heart disease patients and more than ½ of the world's cardiovascular deaths. As a matter of fact there is a 40% higher chance of death from heart attacks among South Asians than the average population. Country-wise, China has the highest number of heart disease deaths, followed closely by India & then Russia, the United States and Indonesia. Moreover, 25% of heart attacks occur under age 40 in the Indian sub-continent and 50% occur under age 50. Tragically, South Asians (India, Pakistan, Bangladesh, Nepal, Bhutan, Maldives and Sri Lanka) are perhaps genetically predisposed so that coronary artery disease (CAD) occurs up to 10 years earlier, having 4 times more risk than the general world population, on average. Thus prevalence of CAD in the Indian subcontinent is presently one of the highest and is further on an increase. The Kashmiri population is undergoing lifestyle changes even more than other sub-groups and as a consequence suffer from even higher risk. In a recent study, the overall prevalence of CAD in the general Kashmiri population was 7.54%; rural - 6.7% versus urban - 8.37%. Furthermore, CAD prevalence was higher in males: 7.88% and slightly lower in females: 6.63%.
What is causing this heart disease phenomenon in Kashmir?
South Asians tend to be smokers, and the typical South Asian diet tends to be high in sugar, refined grains, and fatty foods and low in fiber; both soluble and insoluble. On top of that JK & Ladakh in particular have high consumption of red meat and saturated fat; butter and ghee.
An alarmingly high number of South Asians appear to be insulin resistant, a pre-diabetic condition in which the body does not process insulin efficiently. Insulin-resistant patients have similar rates of cardiovascular events as those with full-blown diabetes. In South Asians, diabetes and insulin resistance affects up to 20% of the population.
Sedentary lifestyle, high-calorie food and reduced physical activity are contributing to the increase in sudden heart attack in young people. Even people in hilly areas who previously used to work in uneven terrains and climb mountains as part of their daily activity have now given up their active life-style.
Body mass index (BMI) in South Asians often falls into a thin-fat syndrome: Obese (High BMI) individuals have a higher risk of CAD. However, people of the Indian sub-continent may have an acceptable BMI, but they still carry more of their weight in their abdomen (central obesity) and that visceral fat is more likely to lead to a cardiovascular event. This risk is in addition to the risk of being over-weight.
South Asians also develop Type 2 diabetes, high blood pressure, high triglycerides, and high cholesterol at lower body weights than the general population. More than 1/3 of South Asian men and 1/6 of South Asian women have metabolic syndrome. Metabolic syndrome is a cluster of conditions including:
1. High blood pressure
2. High blood sugar levels
3. Excess body fat around the waist
4. Abnormal cholesterol levels that increase the risk of heart disease, stroke and diabetes
Recent studies suggest that metabolic syndrome and abdominal obesity may play a causative role in both the prevalence of diabetes and the premature atherosclerosis noted in South Asians.
South Asians are more likely to have high triglycerides and low HDL (the good cholesterol).A variant of HDL known as HDL2b, which is thought to mediate the good effects of HDL, is low in as many as 93% of South Asian men and 63% of women. Cholesterol problems are very common among South Asians due to genetic risk, lack of physical activity, and suboptimal dietary habits. The likelihood of dying from heart disease in young people doubles with every 40 point increase in total cholesterol.
The cardiovascular risk in South Asians appears to begin early: Research has shown that even in infancy, children of South Asian heritage may have high levels of cholesterol and lipoproteins in their blood.
However, these classical risk factors only partially explain the risk in Kashmiris. The important factors that add to these in Kashmir are cold weather, high consumption of red meat and other social issues.
How to lower risk of heart disease?
Genetically susceptible individuals develop abdominal obesity and insulin resistance when exposed to a toxic environment of reduced energy expenditure but increased caloric consumption. This pattern is increasingly noted in parallel with urbanization, suggesting that the increased cardiovascular risk in South Asians may be preventable through lifestyle interventions and the judicious use of medicines to attain optimal levels of blood pressure, lipids and glucose.
Steps in reducing heart risk?
1. Awareness - Awareness of increased risk at an early age is an important first step. That awareness should include awareness of family’s health history as is available.
2. Guidance - Talking with a doctor knowledgeable about this type of heart disease will also help. Adding daily exercise and eating heart-healthy foods will also contribute to lowering heart disease risk.
3. Proper testing - What compounds these risks in the South Asian population is a lack of specific testing: The criteria for metabolic syndrome and the sub-fractionation of HDL and other lipid- and inflammatory-based cardiovascular risk biomarkers are typically not checked during routine physical exams and they are often overlooked in a standard cardiovascular workup. These tests should be included in the standard screening of populations, at least those who are at high risk.
4. Maintain the numbers - What numbers should be maintained?
o BLOOD PRESSURE - 120/ 80 mmHg
o BLOOD SUGAR – 60-99 mg%
o TOTAL CHOLESTEROL – 150-220 mg%
o BMI - <22.5 kg/m2
o PHYSICAL ACTIVITY - ≥ 10,000 steps / day
5. Healthy eating –
o Eating mostly vegetables, fruit, beans, nuts and whole grains.
o Limit red meat to a few times each month.
o Limit processed foods and always check nutrition labels of packaged products
o Avoid butter & ghee, instead use mustard oil, rice-bran oil or groundnut oil
o Olive oil can be used for light cooking and sprinkling on salads
o Don’t overcook your vegetables but try to consume in steamed or lightly cooked forms. Some vegetables and most fruits can be even consumed raw.
o Avoid reusing oil again and again
o Avoid food cooked outside home (dhaba, restaurants etc), bakery foods, ghujiya etc
6. Exercise your heart
o 30 min of regular exercise every day or ≥10.000 steps / day is all it takes to make a real diff¬erence.
o Isotonic exercises like brisk walking, walking the dog, gardening, and using the stairs count can help your heart.
o Yoga with its balanced program could be a very good comprehensive exercise
7. Stop smoking - People who quit smoking before age 50 have 50% less risk of dying in the next 15 years compared with people who continue to smoke
8. Purchase activity / fitness tracking devices like fit-bit, apple watch etc and start using it to monitor daily exercise activity etc.