Coronary Artery Disease (CAD), which refers to the blockage of blood vessels supplying the heart muscles due to deposition of cholesterol, was long believed to be a disease affecting the elderly population. Recently, however, disturbing reports have emerged showing a distinct pattern of younger patients being affected by this disorder. There have been a spate of high profile deaths from heart attacks, most recently of Bollywood singer Krishnakumar Kunnath, actors Siddarth Shukla & Punith Rajkumar – all strapping, young stars of the tinsel world in the prime of their careers.
CAD Rages In Pandemic Proportions!
Recent scientific evidence shows alarming findings; the rates of CAD among Indians are a staggering 50-400% times that of any other ethnic group. While prevalence of CAD in the West has gone down by half in the last three decades, the rates in India have doubled with no signs of abating. The average age at which the first heart attack occurs has come down by 20 years in Indians, a fact that has been highlighted by the above-mentioned high-profile tragedies. The first heart attack among Indian men occurred in 50% under the age of 50 years and in 25% under the age of 40. Moreover, this pandemic of CAD, hitherto considered a preserve of the affluent class, has of late been found to be cutting across socio-economic and gender bias to afflict, with equal ferocity, the low and middle income classes, as well as the women. Even the rural-urban divide, though still significant at 3-4% in rural, as compared to 8-10% prevalence of CAD in urban areas, too is getting blurred. The severity of the disease also is higher in Indians, with a greater prevalence of all three coronary arteries being involved than in Western populations. In fact, the ongoing Covid pandemic has also thrown up the disturbing finding of an increased incidence of heart attacks as one of its many presentations.
Why Are Indians So Susceptible To Developing CAD?
Indians are prone to developing CAD, when in fact, the conventional risk factors for CAD like hypertension, high cholesterol, obesity and smoking are lower in incidence in Indians than westerners. The answer to this question lies both within us and our immediate environment.
Indians today are undergoing a major socio-economic & cultural shift. The policies of economic liberalization have exposed us to a plethora of lifestyle and dietary changes in the last three decades. A greater proportion of people are now urban-dwellers, with a corresponding decrease in physical activity, more consumption of refined sugars and carbohydrates (calorie dense), high fat diet loaded with trans fats and such other atherogenic lipids, topped by psychological stress and reduced levels of physical activity. All these lead to a heady mixture of obesity, high blood pressure, diabetes and development of bad cholesterol profile in the blood producing a milieu interior of inflammation, cholesterol deposition and blood clot formation, leading to heart attacks and a host of other life style related diseases like various forms of cancers, strokes, mental depression, hair loss, loss of sexual libido etc. It has long been known that Indians, and in fact the entire South-East Asia, as an ethnic group are genetically predisposed to developing CAD. This is illustrated by these interesting “paradoxes”:
Japanese paradox: Despite a 74% incidence of smoking, Japan has a five-fold lower CAD rate than the USA. Along with its economic might and urbanization, Japan has reduced its CAD rate by 60%. The factors contributing are a high level of HDL (the “good “cholesterol”) and low levels of triglycerides (the “ugly” cholesterol), along with a high consumption of fish.
Chinese paradox: The new economic/geopolitical powerhouse status of China and a high incidence of smoking and hypertension have not translated into a higher incidence of CAD and mortality therefrom. Here too, the favorable lipid profile is largely responsible.
Asian Indian paradox: Indian immigrants in the US have a 4-fold higher incidence of CAD than their American counterparts despite a lower prevalence of conventional risk factors as noted earlier. This is an off shoot of our genetic predisposition to insulin resistance and diabetes, higher levels of bad cholesterol (Triglycerides), lower levels of good cholesterol (HDL) and higher incidence of hypertension.
Our genetic baggage: The entire South-East Asia is genetically predisposed to a higher prevalence of CAD. Newer unconventional risk factors have emerged as a result of scientific research that put us to this higher risk. These are:
The “deadly” cholesterol – This is the name given to Lipoprotein (a), a variant of LDL (the “bad” cholesterol). It is a powerful predictor of development of cholesterol plaque and clot formation in the coronary arteries. In fact, a high childhood level is a major marker of future premature CAD development. Shockingly, levels of this marker have been found to be higher in Indian newborns than their Chinese counterparts. This has also been found to exert a synergistic effect with other risk factors like smoking, obesity, diabetes, etc in the development of CAD.
Homocysteine – This molecule has recently been identified as an independent risk factor for CAD in Indians, being higher than in white populations. A very small rise in its levels is associated with an exponential rise in CAD incidence.
Other emerging biochemical risk factors like apolipoprotein B, Plasminogen Activator Inhibitor, Fibrinogen and c-Reactive Protein have been detected in higher levels in Indians than in other ethnic groups.
All of the above goes to show that we are rendered susceptible to early development of more severe CAD by a deadly combo of genetic and environmental factors, a kind of double whammy.
Preventive and Promotive Measures
The moot question thus arises – what can we do to save ourselves? What measures can, and should be, adopted at individual and national levels to prevent, or at least slow, the progression of this pandemic? A practical template can be as follows:
- Early lifestyle modification: It is imperative that precautions should be taken to avoid this catastrophic and devastating disease right from birth, and not later on in life only. In studies carried out in infants, it was found that fat deposition in the arteries of the heart could be demonstrated in children less than 1 year old. Therefore, we need to catch them young and healthy habits should be inculcated right from childhood in form of increased physical activities, prudent dietary changes, sensitization against childhood obesity and tobacco usage.
- Physical Activity: It is common place to occasionally see an obese person living a healthy life and some of those absolutely lean and thin people getting heart attacks. So not only is it important to keep the weight under check, but it is equally important, or may be even more, to be physically active and exercise regularly. It has been categorically demonstrated that physically active, but mildly over weight men have a lesser chance of developing CAD than a physically inactive but normal weight or lean person. 30-40 minutes of aerobic exercises (walking, jogging, cycling, swimming etc.) and 15 minutes of resistance exercises of the major muscle groups are recommended on daily basis. For the busy bee, exercise can be done in aliquots of 10 minutes also, whenever one finds time.
- Dietary modifications:
- Avoid Saturated fat: This is a major source of elevated cholesterol and triglycerides. A glaring example is that of Kerala, which has the highest consumption of coconut oil in the country, as well as the highest incidence of CAD. Coconut oil is a major source of saturated fat. Hence it is recommended that the consumption of these products be limited to just one tablespoon per day. Other sources of saturated fats include dairy products, butter, red meat, etc.
- Prefer Mono-and Poly unsaturated fatty acids (MUFA and PUFA): Increasing the proportion of these fatty acids lowers the proportion of LDL. Nuts, olive oil and Canola oil are a rich source of these. Caveat – Use in moderation.
- Never reuse oil for deep frying: This is a common but dangerous practice, especially in India’s famed street food stalls. It leads to formation of more saturated fatty acids and trans fats and a tendency to cholesterol deposition (plaque formation) in arteries of the heart.
- Obesity should be a taboo: It is not the absolute weight, but where that weight is located, which is more important. In India, we have a penchant for developing a paunch and it is this fat located in the abdomen, called central or visceral obesity or more colloquially, pot-belly, which is associated with deposition of cholesterol and blockages in the arteries of the heart rather than, peripheral obesity in which extra fat is deposited either in the hips or in the shoulders. So in parlance of health, ‘waist is waste’, and the waist circumference in the men should preferably be less than 90 cms and that in women less than 80 cms.
- Stress Relief: The prominent personalities mentioned at the start of this article were all considered “Fit” by our modern, consumerist standards, that is, all had chiselled, adonis-like bodies. That is not to say that they were truly fit from a medical sense. Fitness also implies a mental state of contentment, bliss and rest, both physical and mental. How many of these stars got adequate sleep, and were stress-free? How many of them were TOTALLY free of any form of addiction? Physical fitness and endurance, whilst being of paramount importance, MUST be complemented by adequate rest and rejuvenation, stress-busting activities and a state of mental contentment. It cannot be defined solely on the basis of gymming and sculpted bodies. However, Yoga, transcendental meditation, music, walking and increased time with family and friends are proven and effective stress busters. If need be, take professional help
- Absolute abstinence from tobacco and substance abuse: Smoker’s risk of developing CAD is 24 times that of non-smoker irrespective of type of smoke – be it smoked or smokeless (Tobacco chewing /sniffing etc), and exposure to second hand smoke (Passive smoking) is just as bad as smoking own self. So a ‘BIG No’ to tobacco intake in any form and through any route.
- Avoid/prudent alcohol intake: It is a myth that alcohol prevents CAD. Avoid alcohol, but one should not carry any guilt if alcohol intake is restricted to 30-60 ml/day of hard alcohol (42% – Whiskey, Gin, Vodka, Rum etc.) or 375 ml of beer or 150-200 ml of wine.
- Health screening: Lastly a ‘stitch in time saves nine’ and therefore regular health checks are prudent health practices with rich dividends. Since Indians have a lower incidence of conventional risk factors (except diabetes) as compared with Whites, it follows that specific screening of blood for unconventional risk factors like Lipoprotein (a) and Homocysteine should be carried out in Indians, especially in those at high risk for developing CAD for example, those with a strong family history of the disease.
- Beware of pollution: Of late, the steep rise of PM2.5 levels in our air has set alarm bells ringing in medical circles. These pollutants, by virtue of their smallness (less than 2.5 microns) directly enter the bloodstream and cause blockages of the coronary arteries. Future recommendations will undoubtedly include protection from, and mitigation of the effects of air pollution.
To conclude, the present scenario calls for immediate efforts on the part of all stake holders, viz. individuals, society & government, to adequately screen individuals at risk for CAD, especially those with family history of CAD, smokers, obese and those having conventional or nouveau risk factors as enumerated supra. Pari passu, aggressive preventive measures should be incorporated in the lifestyle, with a view to offset the potential time bomb of CAD, that will be upon us with a greater fury in the near future. However, it goes without saying that rather than waiting for the government to get things done, it is in our own interest to adopt sensible, pragmatic and prudent lifestyle and behavioral changes in ourselves and our offspring.
(Dr. O.Yadava, C.E.O. & Chief Cardiac Surgeon, National Heart Institute, New Delhi)
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