Not so young at heart
Rajeev Bhardwaj, head of the cardiology department at the Indira Gandhi Medical College (IGMC), Shimla, was not surprised when he received a youthful Prashant Saini as a heart patient last year. Saini, who is in the merchant navy, was home for vacation in Solan. The 22-year-old man had decided to spend time on his favourite leisure activity. Trekking to Lahaul-Spiti, 300 km from his hometown, he was forced to stop at Poh village due to heavy rainfall and landslides. Here he felt an excruciating pain in the chest. The stopover turned out to be a boon as he was still close to a hospital. Doctors told Saini he had suffered a severe heart attack. After initial treatment, he was taken to IGMC.
Bhardwaj started witnessing the trend in mid-2000s. He remembers a boy, barely in his early 20s, who reached the hospital with severe chest pain. He needed angioplasty, which is done to mechanically widen obstructed arteries through a ballooning process. The doctor also talks about a 28-year-old man on whose heart he had to place a stent, a tube-shaped mesh which is inserted into the artery to hold it open.
“In my 30 years of work experience, this was the first time that people in their 20s and 30s were coming to me with blocked arteries and heart attacks. Till this time, heart ailments in youngsters were very rare,” says Bhardwaj. The worrying trend prompted Bhardwaj to investigate further. He started studying all cases of under-40 patients the department had received since mid-2009. The result was startling. Within three years, IGMC had received 124 young heart patients, or one youngster every nine days. More worrying was the fact that most of them had suffered the worst form of heart disease.
Nearly 60 per cent of the patients had blocked left anterior descending (LAD) artery, the ongoing study found. “There are three main vessels in the heart—LAD artery, aorta and pulmonary vein. Blockage of any of these can cause an attack. But LAD is the biggest artery. When that gets clogged, it has the worst and long-term effect,” he explains.
It is the most common reason for heart attack among all age groups, but never was it considered a problem of the young, says Ashok Seth, director of Fortis Escorts Heart Institute, Delhi. Seth analysed the trend along with Peeyush Jain, head of the department of preventive cardiology. Of the total number of cardiac patients the hospital received, the number of under-25 patients had jumped from two per cent (four patients) of the total in 2004 to 25 per cent (206 patients) in 2011. The analysis was released in February 2014. The percentage of under-45 patients doubled, from 3.5 in 2004 to 7.3 in 2011.
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Numbers from rural Andhra Pradesh testify the pan-India scenario. Heart diseases was found to be the leading cause of deaths in 45 villages of East Godavari and West Godavari districts. Of these, 27 per cent were young—between 15 and 59 years, which forms the productive age group (see ‘Who is young’). The study, conducted in 2006, was led by Rohina Joshi of the Australia chapter of George Institute for Global Health. “The two districts studied are better developed than many others in the state. However, the primary employment of people here is agriculture and aquaculture, not different from many other parts of the country,” it states. The study was published in the September 22, 2006, issue of International Journal of Epidemiology.
INTERHEART, a study conducted in 52 countries, showed the trend about a decade ago. The study was led by Salim Yusuf of McMaster University and Hamilton Civic Hospital Research Centre, Ontario, Canada. The 2004 study found that 11.7 per cent of the Indians who suffer their first attack are below 40 years. The worldwide figure for this is six per cent. Among Indian men who have suffered a heart attack, 12.7 per cent are younger than 40, while the corresponding world figure is 7.2 per cent. The percentage of women less than 40 years of age who suffered heart attack is 11.9 in India, while the world figure is only 2.3 per cent.
The sprinkling of studies show the growing trend. But India has not yet woken up to the enormity of the problem. It still does not have a countrywide data on the heart diseases for adequate understanding of the trend. Only after data is available can researchers diagnose the causes and policymakers frame policies.
|Who is young?
Studies conducted in India and abroad have used varied age groups to define the young. Rajeev Bhardwaj, head of cardiology department at Indira Gandhi Medical College, Shimla used less than 40 years as the benchmark. The INTERHEART study, conducted in 52 countries by Salim Yusuf of McMaster University and Hamilton Civic Hospitals Research Centre, Ontario, Canada, also keeps below 40 years as the benchmark. This is the most acceptable cut-off for researchers. But to analyse the country’s economic loss due to heart diseases, understanding their effects in the productive years of life (15 to 60 years) is important. The Government of India defines 30 to 59 years as young.
“The defining age for different authorities and researchers is determined by the corresponding data available for risk factors, leading to a heart condition,” says Rajeev Gupta, cardiologist at Fortis Healthcare, Jaipur. “Absence of uniformity points to the fact that there are no targeted interventions to fight the challenge posed by heart diseases,”says Peeyush Jain, cardiologist at Fortis Escorts Heart Institute, Delhi.
At the heart of the problem
Factors that cause heart diseases are the same among the young and the old—abnormal lipid levels in the blood, smoking, hypertension, diabetes, abdominal obesity, psychosocial stress, low consumption of fruits and vegetables, consumption of alcohol, and lack of physical activity, states interheart study. When Bhardwaj investigated Saini’s case, he found the youth was a heavy smoker and had developed the habit very early in life. Despite his profession keeping him physically active, Saini’s heart broke his trust. He was fortunate that the heart attack was not fatal. Mortality among youth is low after an attack, compared to the elderly. However, once a person gets a heart disease, it leads to a life-long togetherness with medicines, restricted diet and related illnesses. So it has to be taken seriously, especially with more than 50 per cent of the Indian population less than 30 years old, says Rajeev Gupta, cardiologist at Fortis Healthcare, Jaipur.
“Smoking is the most common factor among young patients who come to me,” says V K Bahl, head of the cardiology department, All India Institute of Medical Sciences (AIIMS), Delhi. Bhardwaj’s study corroborates this. As many as 58.8 per cent of the young patients he studied were smokers.
Toxins released in the blood due to smoking, and hypertension injure the arteries and lead to heart ailments, says Gupta. The injured area becomes the lodging space for fat and cholesterol. As these accumulate, they narrow down the space for the blood to flow, causing heart problems.
Consumption of alcohol works as a protective measure worldwide, but it is a risk factor in India despite Indians drinking much less than the rest of the world, states the INTERHEART study. “It is a risk because we engage in binge drinking. We do not drink regularly, but when we do, it is to get highly intoxicated. This pattern of alcohol drinking affects the heart adversely,” says Bahl.
But Suresh Thakur, 38, neither drinks nor smokes. He says stress may have been the reason for his heart troubles. He is a farmer, a volleyball player, a father of three and the main breadwinner of his joint family of 12. He lives in Tharoch, a non-descript village in Shimla. It is believed that heart disease, a lifestyle trouble, cannot affect people who live in the mountains. “It was 2010. That day I played volleyball like any other day. On way back home, I saw wild animals destroying my crop. I chased them away from the field for half an hour. After reaching home I felt acute pain in my chest,” he says. Doctors at IGMC fitted a stent in his heart. “Managing a family of 12 while doing so much physical work is not easy. I repeatedly enroll in college courses to become eligible for the Nerwa district’s government college team. I play intercollege competitions across the state. I do not wish to discontinue my passion.”
Increased stress levels shoot up blood pressure and cholesterol, which strain the heart and can lead to an attack, says Bhardwaj. These are triggered by poor eating habits. In many cases parents introduce unhealthy diet to children. “Many diseases that develop later have their origin during childhood, teenage or early adulthood,” says Bhardwaj.
Shivpuri, a district in Madhya Pradesh, is largely inhabited by the Sahariyas, a tribe that once entertained local rulers by fighting ferocious animals. The district administration has converted many of its forest land into reserved forest, forcing the Sahariyas to move out of their natural habitat. The nutritious food that the forests gave them is no longer for them, says right-to-food activist Raghavendra Singh. Their staple meal now is chapati and chutney. When hungry, children get small packets of Chhota Bheem, a Kurkure-like locally made snack, which costs just Rs 2. The Sahariyas eat vegetables only about twice a week because of the cost. The market is far away and they do not have land to grow food themselves. The 2009-2010 National Sample Survey states that per person expenditure on vegetables in rural Madhya Pradesh is abysmally low at Rs 67 per month. Hypertension level in a young Sahariya male (between 17 and 46 years) is as high as 21.6 per cent, states a 2012 study done by the Department of Anthropology University of Delhi with the Institute of Applied Health Sciences, University of Aberdeen, UK.
A 2012 investigation by Delhi-based non-profit Centre for Science and Environment shows that Maggi Noodles, a favourite among children, contains 3.5 grams of salt. This is 60 per cent of the total daily salt intake recommended by the National Institute of Nutrition, Hyderabad. Food companies also have a history of providing incomplete or incorrect information to consumers (see ‘Oil’s not well’). “Anything off the shelf is dangerous. Processed food is unhealthy, be it biscuit or other ready-to-eat food,” says Seth.
|Oil’s not well
A war is on among advertisers of edible oil companies who want to make a place in people’s hearts. For nearly two decades, Saffola ran its advertisement with the famous tagline, “Swasth parivaar ke dil ki dhadkan (heartbeat of a healthy family).” “What the company claimed was not true. Saffola had elements which are harmful for the heart,” says S C Manchanda, cardiologist at Sir Ganga Ram Hospital and campaigner for healthy oil. After more research, Saffola now has a mix of different oils.
Edible oil should be free of cholesterol and trans fats, have low saturated fats and should have Omega-3 nutrient. Only mustard and canola oils meet these requirements, he says. Mustard oil is produced in India and is, therefore, cheaper than most oils, canola oil is imported from Canada and cost at least Rs 260 per kg.
Refined oil is bad for heart because it gets heated at a high temperature. Olive oil is heart-healthy as it heats up early, but it is not as good as mustard and canola oils because it lacks Omega-3, adds Manchanda.
But children prefer processed food, which contains high amounts of salt, sugar and saturated fat, to vegetables.
Nutrients and fibres in fruits and vegetables help remove cholesterol from the arteries and are essential to keep the heart running, says Rekha Sharma, president, Indian Dietetic Association and former chief dietician at AIIMS. But Indians eat these less than the rest of the world, she says.
Across the country, the per capita monthly expenditure on fruits and vegetables is poor—Rs 57.20 on vegetables and Rs 11.76 on fruits in rural areas, and Rs 76.66 on vegetables and Rs 29.53 on fruits in urban areas. Consuming fruits and vegetables is a challenge across the country. “We give fruits only to our children,” says 31-year-old Sunita Kumari of Deothi village in Solan. High cost is a problem across India.
This apart, youngsters are no longer as active as the earlier generation used to be. The prime reason for this is dependence on machines. “The young depend on motorised transport as much as the old and the needy,” says Bhardwaj. He gives an example. To save the elderly of the steep climb on foot, the authorities in Shimla started a cab service from Old Bus Stand to Mall Road, a 3-km distance. “But the youth occupy the cabs as much as the elderly. Love for walking is at an all-time low,” he says. It is not just lifestyle that weighs heavy on the heart. In 2010, outdoor air pollution contributed to over 620,000 premature deaths in India, up from 100,000 in 2000. The analysis by Boston-based non-profit Health Effects Institute shows that 48.6 per cent of these were because of heart problems. Air pollution levels were much less earlier, so people suffered its ravages much later in life. Young people spend a large part of the day outside and are likely to be more exposed to air pollution. This may be one of the reasons for the trend. To assess the impact of exposure to particulate matter in the air on heart, Helmholtz Zentrum München, a German research centre for environmental health, tracked the health of 100,000 people for 11.5 years. During the period, 5,157 people suffered heart attack or unstable angina, both usually caused by deposition of calcium in coronary vessels, which narrows arteries leading to heart diseases.
A heavily polluted environment and poor lifestyle combine to threaten our youngsters much earlier now. It was believed that South Asians are genetically more prone to heart disease than people in the rest of the world. The INTERHEART study for the first time proved that lifestyle is a bigger culprit than genes in India. Tobacco and abnormal lipid levels in India contributed to more than two-thirds of the risk. This suggests that tobacco control, improved diet and physical activity may have huge implications for Indians.
Genetic or environmental, most of the reasons for heart ailments are not in an individual’s control. Worse, they are negligent towards their health. Most youngsters reach a doctor only after their small ailment becomes a full blown disease.
Back in 1974, Gaurang Patil, then 26, was playing hockey in a village in Solan when he had a blackout and started perspiring heavily. A favourite among his coach and team, he was back on the field within a few days. Over the years, his stamina started diminishing, but he paid little attention to it. He would intermittently feel unwell and could not understand the reason for it. Twenty years later, doctors found that his arteries were blocked. Then began a series of treatments, and by 2004 he had had three heart operations. “Doctors tell me I would have been healthier had my condition been detected earlier,” he says.
|Sahariya tribals of Madhya Pradesh do not eat enough vegetables, which help curb hypertension. A Delhi University study has found that 21.6 per cent of the Sahariya men (between 17 and 46 years) have hypertension
Rohina Joshi’s 2008 study done in rural Andhra Pradesh shows there are a lot of people who are not even aware of the problems that can lead to heart diseases. Of the total individuals diagnosed with heart ailments, 44 per cent did not know that discontinuation of smoking can prevent heart disease. Only 50 per cent knew the benefits of physical exercise, 62 per cent knew that they should avoid fatty food, and 62 per cent knew the benefits of reducing salt in their diet.
There is clear evidence of the increasing disease burden among the young, but the government has done precious little to ameliorate the problem.