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When will heart disease be tackled on a war footing?

NewsWhen will heart disease be tackled on a war footing?

Heart disease has reached epidemic proportions in India and the nation is helpless.

Washington, D.C: Ramesh Chand, a 42-year-old chartered accountant in Delhi, woke up in the morning at 4 am with severe pain in the jaw so hard that he thought it would explode. He woke his wife and before they could do anything about it, he became unconscious. His wife called the ambulance and upon arrival at the hospital, he was declared dead. Cause: coronary heart disease.
Heart disease has reached epidemic proportions in India and the nation is helpless. The Global Burden of Disease study reports a coronary heart disease death rate of 272 per 100,000 population in India which is much higher than the global average of 235 and among the highest in the world. Of particular concern is that it is striking Indians at an earlier age, showing fast progression, and causing a higher number of deaths than ever before. Within India, Kerala, Punjab, and Tamil Nadu have the highest rates because these states also have the highest rates of elevated cholesterol levels and high blood pressure. Heart disease in urban areas is as high as 9-10%, which is a ten-fold jump from 60 years ago and in rural areas 4-6%, which is a five-fold jump from 60 years ago.
The INTERHEART study identified nine risk factors that are contributing to 90% of heart disease in South Asians. What are these? Smoking, high blood pressure, diabetes, high cholesterol with related abnormalities, obesity, physical inactivity, low fruit and vegetable intake, psychosocial stress, and family history. While family history is non-modifiable, other risk factors are all modifiable.
First, quitting smoking can help the heart immensely. At the individual level, each smoker should make a definitive quit plan. According to a survey, almost 37% of Indian smokers want to quit smoking. However, India has the lowest quit rates for smoking in the world. At the policy level, the government is content just promoting a national Quitline through a toll-free number (1800-11-2356) and has launched a pan-India, “m-cessation” initiative. Is this enough when we already know that these measures are toothless? There is a need to build quitting programs on culturally and empirically robust fourth-generation frameworks such as the multi-theory model (MTM) of health behaviour change. In this approach, the start of quitting is guided by swaying the decision toward the advantages of quitting, promoting behavioral confidence, and providing tangible support. The continuation of quitting is assisted by transforming emotions into goals, building constant awareness about quitting, and mobilizing social support from family, friends, and others.
Second, high blood pressure affects a large number of Indians. According to a national survey, 25% of Indians have high blood pressure with greater rates among men (27.4%) than women (20.0%). This is definitely a low estimate because a substantial number of Indians do not visit doctors and do not know their blood pressure. Therefore, in this regard, there is a need for education to encourage every Indian to visit a doctor and ask them what their blood pressure is and get it managed. This also entails overcoming the “fear” of taking antihypertensive medications. We need to remember that the medications are prescribed keeping in mind the benefit-risk ratio with benefits far outweighing the risks or adverse effects. At the policy level, India has established a target of a 25% reduction in the rate of high blood pressure by 2025 which is a great start. But will this plan work when currently only 12% of hypertensives have their blood pressure under control? And more importantly, will this target be sufficient? Unless measures are taken on a war footing it is difficult to see the true impact of these efforts.
Third, India has the highest cases of diabetes in the world with about one in ten having high blood glucose. Some of the same risk factors for heart disease are also the risk factors for diabetes thus causing a vicious cyclical relationship.
Fourth, several studies have shown that among Indians high cholesterol is present in 25-30% of the urban population and 15-20% of rural residents. A substantial number of Indians do not know what their cholesterol numbers are. Hence there is a need for campaigns to encourage each Indian to ask their doctors to get blood tests done and ask questions as to how to bring those in the normal range if needed. Once again, the “fear” of medication should not be a deterrent.
Next, obesity, physical inactivity, and low fruit and vegetable consumption all go hand in hand with healthy eating and exercise behaviors. Among Indians, about 19% of men and 21% of women are overweight or obese which in itself has reached epidemic proportions. Modern-day sedentary life coupled with Indians consuming high carbohydrate diets with irregular dietary habits is a big contributor to the problem of obesity. While about half of Indians are primarily vegetarians which to some extent is protective but the large consumption of amounts of carbohydrates, full-fat dairy, butter, ghee, and cheese in daily meals is troublesome. High rates of heart disease in Kerala and Punjab are due to high-fat consumption in the diet. Once again, there are only Band-Aid types of solutions addressing the problem of obesity in India. At the policy level, these need to be escalated to battle-ready levels.
Finally, psychosocial stress is a big culprit which is silently contributing to the causation of heart disease and needs to be addressed at all levels. Stress has become ubiquitous in present-day life. At the individual level, effective coping education needs to start in schools and colleges. Stress management should be a required course. Topics such as identification of stressors, relaxation/meditation, effective communication, anger management, anxiety reduction, time management, financial management, regular exercise, healthy eating, and making stress reduction plans should be taught in varying levels of sophistication starting from middle school all the way to college. In addition, worksites should regularly hold wellness and stress management workshops. At the policy level, the government should provide incentives and schemes for such programs so that these get institutionalized.
It is time to wipe out heart disease before it engulfs more premature lives!
Prof Manoj Sharma is Chair of the Social and Behavioral Health Department at the University of Nevada, Las Vegas.
Maneesh Pandeya is a Fulbright Professor and Ph.D. Scholar at Howard University in Washington DC.

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