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.

Related Interview   ‘Mass media campaigns can curb tobacco consumption significantly’ Tobacco is the leading cause of heart diseases among the young. Nandita Murukutla, country director (India) of non-profit World Lung Foundation, says mass media campaigns are effective in discouraging the youth from taking to tobacco—smoking as well as chewing varieties. Excerpts of her interview with Jyotsna Singh

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.

Despite the growing trend and locallevel initiatives, the government’s approach to tackle heart diseases among the young is inadequate

It’s nothing short of an epidemic, says Anshu Prakash, joint secretary, non-communicable diseases (NCD), Union Ministry of Health and Family Welfare. Compared to the rest of the world, India loses the maximum manhour of productive population (between 35 and 64 years) due to heart diseases. In 2000, the country lost 9.2 million years to heart ailment. The loss is expected to increase to 17.9 million years by 2030. This is 940 per cent more than the corresponding loss in the US which has one-third the population of India, says Prakash.

Formulation of a policy to prevent this is possible only if information is available. The government was eagerly awaiting the result of the Million Death Study (MDS) which was launched in 1998, say sources. MDS, conducted by the Centre for Global Health Research, University of Toronto, in collaboration with the Registrar General of India, aims at monitoring the causes of 1 million deaths in India and collect data according to age, gender and region. The study was publicised as the most reliable data set in the current scenario that could establish the reasons for heart ailment among the young. But sources told Down To Earth that the study, which is in its final stage, may not see the light of the day at all because of disagreements between the two organisations. At present, India does not have a targeted programme to tackle growing heart diseases among the young. In 2008, the health ministry launched the National Programmed for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) to understand non-communicable diseases and to mitigate the challenges posed by them. But it collect data of only people above 30 years of age. It did not collect age- or gender-specific data.

The programme focuses on early diagnosis, management and prevention of non-communicable diseases, and strengthening of infrastructure. It aims to set up NCD clinics and cardiac care units in each district. The first screening of high-risk patients is done at the sub-centre where their blood pressure and blood sugar levels are recorded. The staff at the sub-centre refers suspected cases to the primary health centre or the community health centre. If found at risk, they are referred to the cardiac care unit or NCD clinics for treatment. Depending on the number of suspected cases they get, the health centres are chosen for setting up NCD clinics and cardiac care units.

The programme’s pilot project was launched in one district each of 10 states. In 2010-12, it was implemented in 100 more districts in 21 states. This year, 140 more districts were brought under the programme. By the end of the 12th Five Year Plan in 2017, the Centre plans to extend the programme to all 640 districts.

But the programme failed to achieve its aim. The government was unable to even start the programme at 20,000 sub-centres in 100 districts by 2012, leave alone choose 700 community health centres to start NCD clinics. Till now, there are only 72 NCD clinics at community health centres and 64 NCD clinics at district hospitals. NPCDCS itself is inadequate, as it does not have any provision to check the growing trend of heart diseases among the young. Most primary health centres do not have a cardiologist. Forget about long-term treatment, even emergency service, which is crucial in heart attacks, is not available. At present, India has just about 3,500 cardiologists. These, too, are mostly concentrated in urban areas. In absence of adequate infrastructure, the cost of treatment is high and out of reach to a major part of the country’s population.

When Hemlata Nair was 31 years old, she went to Fortis Escorts Heart Institute, Delhi, where doctors found that her heart had multiple blockages. She has undergone five angioplasties in the last 13 years. Each angioplasty costs Rs 3.5 lakh to Rs 4.5 lakh. “I have to get my lipid profile checked every third month, which costs Rs 6,000 to Rs 7,000. I shell out Rs 2,500 every month for medicines,” she says. Nair is a nursing faculty member at Jamia Hamdard University, Delhi, while her husband teaches at management institutes. Her treatment is a burden on the couple’s pocket.

Treatment even in government hospitals is not affordable. Surya Prakash, 46, is also struggling to make ends meet after a stent was placed in his heart at IGMC. A government servant at the agriculture department, he had suffered a heart attack in October 2013. The stent cost Rs 60,000 and his medicines cost Rs 2,500 every month.

There are many ways to reduce the cost of treatment and make it available to all. One of the biggest reasons for high treatment cost is stent. Private hospitals mostly provide imported stents that cost up to Rs 5 lakh. Indigenously developed stents cost between Rs 30,000 and Rs 45,000. “The cost of indigenous stent can be reduced if it has more takers,” says V M Katoch, director, Indian Council of Medical Research (ICMR). There is a general preference towards an imported stent. ICMR is conducting a study to prove that Indian stents are as good as imported ones, he says.

In 1995, former president A P J Abdul Kalam, along with cardiologist B Soma Raju and scientist Arun Tiwari, had developed the country’s first stent. The simple metal stent cost a meagre Rs 10,000. By 2001, the stent was fitted in more than 1,000 people in Andhra Pradesh. Though multinational companies saw this as competition and slashed their prices, the government neither popularised it, nor took the initiative for further research. “Metal stents are now outdated. China, Israel, and South Korea started producing and marketing radioactive stents and later drug-eluding stents at lower prices. But India did not develop any of these,” says Tiwari, now head of Cardiovascular Technology Institute of Care Foundation, Hyderabad. “India lost the race despite a good start.” Scientists abroad are now researching on use of nanoparticles to dissolve cholesterol deposition and make stent history.

“But how can a poor man afford even this?” says Sachin Thakur, chief medical officer at Kunihar health centre. A stent’s life is not more than five years. If it is placed in a man’s heart who is in his 20s, by the time he is 70 he would need 24 replacements. The Central government’s health insurance scheme, Rashtriya Swasthya Bima Yojana, designed for below poverty line (BPL) families, gives coverage of up to Rs 1.7 lakh. But the government has allotted only 12 per cent of the budget required to cover the entire BPL population. This makes it impossible to implement the scheme.

Smart initiatives

The government’s policy paralysis has forced non-profits to step in. In December 2012, Centre for Chronic Disease Control (CCDC), a Delhi-based research organisation, initiated M-power in Solan, Himachal Pradesh. The programme uses smart phone apps in its clinical and community interventions to screen and counsel people against diabetes and hypertension. “As part of clinical intervention, we have chosen eight community health centres in Solan and placed a trained NCD care coordinator in each of them,” says D Prabhakaran, director, CCDC. The NCD care coordinator checks the indicators of heart disease, such as the patient’s medical history, blood pressure and blood sugar levels, and feeds them in the smart phone. The app indicates the patient’s condition. The data is also stored for further investigations and research. In the last two months, the health centre at Kunihar alone had 72 new cases of hypertension and 23 new cases of diabetes, says Neelam Kumari, NCD care coordinator at the village.

People with risk factors are referred to cardiologists at the nearby hospitals.

As part of community intervention, NCD care coordinators go house-to-house for detailed investigation. In a 30-minute interview, the coordinator feeds medical history, blood pressure, diet, alcohol and tobacco consumption record of each interviewee in an electronic tab. To keep heart ailments under check, residents are advised to eat healthy food and improve their lifestyle. Till now, CCDC has collected data of 20,000 people and is in the process of analysing it.

A project similar to M-power has been launched in Andhra Pradesh. In August 2013, George Institute of Global Health in Hyderabad, started Systematic Medical Assessment, Referral and Treatment in India, or SMART Health India, in East Godavari and West Godavari districts. The institute trains health workers to feed patients’ medical data into an electronic tab which is transferred to a central server. The patients are treated at the primary health centres. Such projects are being carried out in pockets by institutes and organisations at many places in the country and show a trend. “But to ensure that all citizens benefit, the government needs to formulate targeted cardiac care programmes at all-India level,” says D Praveen, senior research fellow at the institute.

To make cardiac care available to the poor, the Karnataka government developed Yeshasvini Health Insurance Scheme for its farmers in 2003. The beneficiary pays annual insurance amount of Rs 210 and avails healthcare facilities at any of the 476 listed private and government hospitals and clinics in the state. High number of beneficiaries ensure enough money for large scale coverage. The scheme is run through the well-developed system of rural cooperative. In association with the Yeshasvini health scheme, the Narayana Institute of Cardiac Sciences in Bengaluru, better known as Narayan Hrudayalaya, has drastically cut down its treatment cost. While the cost of a heart surgery starts with Rs 2.5 lakh in a private hospital, the Bengaluru-based hospital, founded by cardiologist Devi Prasad Shetty, makes it available at around Rs 1.5 lakh. For this, accountants at the hospital work on a daily basis. They calculate the hospital’s profit of the day and determine the concession that can be given the next day without affecting profitability.

There are times when the cost goes down to Rs 1.20 lakh. The hospital conducts about 30 heart surgeries in a day, double the number in many private hospitals in the country. Due to large number of surgeries, quality cardiac care can be provided at an affordable cost.

Awareness, too, can reduce the burden of disease. To train people on the emergency procedure when a person suffers a heart attack, K K Aggarwal, cardiologist at Moolchand Medicity in Delhi started a campaign to teach CPR, or cardio pulmonary resuscitation. If a person is administered CPR within 10 minutes of getting a stroke, his heart can be revived, says Aggarwal. CPR involves chest compressions at least 5 cm deep and at a rate of at least 100 per minute to pump blood through the heart and thus the body. His organisation, the Heart Care Foundation of India, has taught the procedure to 90,000 people in Delhi in the past one-and-a-half years. The awareness has shown results. “I know of at least 12 cases where people made use of our training and saved people from dying of a heart attack,” he adds.

India needs such initiatives on a national level to reduce heart diseases. The US government, for instance, launched awareness programmes and reduced the incidence of tobacco-related diseases, says V K Bahl, head, cardiology department, AIIMS. It initiated community-based cardiovascular risk reduction programme which was guided by a computerised participant management system and administered by physiologists.

In mid-1990s, cardiovascular disease became the leading cause of death in China, especially in urban areas. INTERSALT, a study conducted in 52 countries in 1980s, showed that salt intake of residents of Tianjin in China was among the highest in the world. So apart from the regular awareness and community intervention programmes, the country introduced the Tianjin Project. Spoons measuring 5 gm on one side for normal people and 3 gm the other side for hypertensive people were distributed. This substantially brought down the average salt intake among people in the city. Within three years, from 1989 to 1992, death from stroke and heart diseases reduced by 15 per cent. The project is known as one of the top successful models ever to control heart ailments.

In Brazil, the government increased minimum wages of labourers to improve their nutrition. Within a few years, non-communicable diseases declined, says Veena Shatrugna, former deputy director of the National Institute of Nutrition in Hyderabad.

The Indian government is still driven by the belief that the number of heart diseases in India is increasing because of the ageing population. “It is important to understand that if we do not save the young now, we will have an unimaginable number of old people with heart ailments a few decades from now,” says Rajeev Gupta of Fortis Health Care, Jaipur.