Heart health: The news is not so heartening

We don’t have concrete data, but over the past two decades it has certainly been growing. 15 years ago, when I was in King Edward Memorial hospital, we saw only one or two under-40 patients per year with a cardiac problem. From there, we have come to a stage where I see at least 10 cases of cardiac-related events, and almost 3 – 5 angioplasties a month, in individuals under 45—most of them being men. That’s a huge shift.

What’s the reason for such a big shift?

There are a few hypotheses. First is the type of food we eat in India and the subcontinent at large, which is carb-rich. 30 years ago there were hardly any fast food restaurants and so we consumed fewer calories in those days. Kids too didn’t consume as much milk and sugar syrup-based foods. There’s a notable difference between the kind of food we ate growing up, and the food that our children eat today. Their dietary habits are unhealthy. Add to this poor lifestyles—they are less involved in sports and outdoor activities—and kids and teenagers around are overweight or obese. So the seeds of heart disease are sown in their early teens.

The obesity that we see in India is worse as most of the fat accumulated is around the tummy [abdominal obesity], which is directly responsible for heart disease. Even women, who generally tend to put on weight around the hips and thighs, are now acquiring apple-shaped obesity and further complications start developing once they hit menopause.

And then there is sugar. The amount of pure refined sugar we eat is simply shocking. People have 6 – 7 cups of tea a day in this part of the world, and the tea is like sugar syrup. So you end up having more than 5 – 10 teaspoons of sugar a day. A recent study by the American College of Cardiology [ACC] has shown that consuming excess sugar is directly linked to heart disease. So the FDA [Food and Drug Administration] in America is planning to soon start warning people about the foods that are safe to consume and those that are not.

What lifestyle and dietary changes do you recommend?

As far as possible, we must cut down on our sugar intake.

Secondly, we must change the way we cook our food. Our cooking is so elaborate that most of the nutrients are lost. We also heat our food a lot, which destroys vital nutrients like B12, pyridoxine and folic acid. If you look at a typical spread in Indian weddings or any buffet in a hotel, you will see a layer of oil floating over the food. Compared to us, Caucasians and Europeans eat more salads and they don’t fry their food as much as we do. We need to cook in a way that preserves nutrients and requires less oil. I mean, don’t burn the food.

The third thing we can do is change our overall attitude towards life. In this day and age, everybody is working harder and for undefined hours. They also have to face the stress of travel, have EMIs to pay etc. Now, I agree that the previous generations had to face stress too, but the amount and type of stress has surely increased manifold. So try and take things a bit easy.

The last thing is that we must pay closer attention to how our vegetables are being grown. Nowadays many of us take pride in declaring ourselves as vegetarians. But do we think about the fertilisers and sprays used in growing these vegetables? Yes, they are linked to cancer but did you know that they can also be a cause of heart disease? I can already see how the concept of ‘contaminated vegetarianism’ will come into the spotlight in the coming years.

Smoking too has an impact but I don’t think it is responsible for the spurt in cardiac cases we are seeing now, as people smoked even 30 years ago. Changes in diet and increase in stress levels are to blame.

At what age should a person start getting routine cardiac checkups done?

If your family has a history of heart trouble, for example either of the parents have had a cardiac event before the age of 55 or you are a smoker, obese, hypertensive or diabetic, you should start going for cardiac checkups from your mid-20s. If there are no risk factors at all, for example, you are a non-smoker or there are no cardiac ailments in the family, then you can start going for annual checkups after the age of 30.

And what should a cardiac check-up involve?

Typically, if there is a family history of cardiac events, we check the cholesterol values. In addition to the routine lipid profile, HDL, LDL, VLDL, triglycerides, blood sugar levels, ECG, etc, it is important to get some other tests done too. They are Lipoprotein[a], hs C-reactive protein and homocysteine levels. Lipoprotein[a] is a type of cholesterol that is extremely atherogenic, which means it is responsible for causing fatty deposits in the arteries, leading to blockages and heart diseases. It is also responsible for causing diseases in the family… so people with high Lipoprotein[a] levels will require early drug intervention, like statins, which reduce cholesterol levels.

Though there is no proven treatment for reducing Lipoprotein[a], taking cholesterol-lowering drugs from a younger age can work well as primary prevention to prevent a cardiac event from occurring in the future. Secondary prevention is when you are already a heart patient and we prevent the occurrence of another cardiac event. These measures can postpone an event by one or two decades, or even completely prevent it.

When are exercise and dietary changes enough? And when are cholesterol-lowering medications needed?

Well, this can only be decided by your physician, but there are few new guidelines issued about five months ago by American Heart Association and ACC regarding who should be
put on cholesterol-lowering drugs. They were recommended for the following groups:

• All diabetics between the ages of 40 and 75.
• Anybody with LDL Cholesterol of more than 190 mg per deciliter of blood.
• Established heart patients who have undergone an angioplasty or a bypass or who have had any other event, even with normal cholesterol levels.
• People who have a cardiovascular risk score of 7.5% or more. This is calculated by the cardiologist with the help of overall parameters like cholesterol, blood pressure values, age, smoking status etc This predicts the individual’s chances of having a cardio-vascular event in the next 10 years.

The thing is, these guidelines are meant for the Caucasian population in America. There are no such guidelines for India. And the disease burden we see in young Indians is not the same as native Americans or Europeans. Even the younger cardiac patients in those countries are mostly Asians. So the occurrence of cardiac events may have something to do with our ethnicity and lifestyle. Chicago-based Professor Enaz, who has done extensive research in lipidology over the last two decades, suggests that we should double the risk score for native Indians and start early drug intervention to reduce cholesterol values.

What about edible oils? How safe are they?

Reusing oil is a strict no for cooking. And transfats are the worst—these are found in vanaspati, dalda and oil that has been used for frying but is reused. Most bakery items and processed foods contain transfats too.

Is it possible to prevent heart disease? What is the role of the doctor in the same?

I will say that coronary heart disease, among all serious diseases, is the most predictable and preventable disease. When a person comes in crashing with a heart attack to the emergency room, I rush and do an angioplasty on him. I save his life and society makes me a hero. But our family physicians who prevent heart disease in many more patients with the advice they give, go unrecognised. The patient doesn’t even realise that his physician may have prevented a coronary artery disease from occurring. I too prevent heart disease in about half the patients I see, if they heed my advice—but they don’t acknowledge it. We as a society do not give importance to prevention. I’ve seen patients who, if prescribed a pill, will go and crosscheck with their family, neighbours, friends or colleagues if they should actually be taking the pill. Sometimes they come back and ask for the dose to be reduced. Today everybody thinks they are cardiologists and dieticians and I am not blaming them—with the incidence of heart diseases going up, everybody has some knowledge of it. But the prevention regime provided by the physician needs to be followed and the mindset of questioning medical advice needs to change.

Are there people who opt for cardiac health check-ups even if they don’t have any symptoms or risk factors?

That is seen only among the elite and affluent class. And yes, if there are promotional packages offered, people grab the chance to get themselves checked. The middle and lower-income class feel that spending money on health is a burden. So even if they go for checkups, they opt for small centres, which are ill-equipped and so don’t give them accurate results.

Do you think the media is creating more panic about heart diseases in the young?

The media memory is short–lived. What is read in the newspaper is forgotten in a day or two. More than the media, a person panics when a colleague of the same age suddenly has a cardiac episode. That’s the time there is a panic in that office, and I would say that it is not a bad thing. If a person has chest pains they should always get themselves checked by a cardiologist or a physician. If it’s a panic episode, it will be addressed accordingly, but some cases of chest pains will inevitably turn out to be actual cases.

What is absurd is that when younger people have cardiac pain, they assume it to be gas or acidity and sit on it until it’s too late. People think, “I am young, how can it happen to me?”—and this kind of denial is deep-rooted.

To a certain extent it has to do with our economy. I have tried asking people why they didn’t come in the night, they don’t answer. But I sense that if they are insured or if their company takes care of expenses, they are more likely to come forward. A patient who was operated upon for an angioplasty kept cribbing about his health even two years after the surgery. He was consulting the family physician in the same hospital as mine, who noticed that the man was very unhappy about having to go through the angioplasty. So the doctor asked him if this life-saving surgery had been performed on him free of cost, would he still be cribbing today? The man didn’t answer then, but he came back next day saying that what was really pinching him is that the surgery had wiped off his savings, and he had hardly considered that it had saved his life. And he never cribbed after that. But I’m sure he’s not the only one who thinks that way.

What is the effect of alcohol consumption on heart health? And what do you recommend to those who like to drink?

There is some confusion in patients about alcohol because you frequently see reports that state that alcohol is good for the heart. However I would like to clarify here that there are a lot of studies conducted in India, including the All India Institute of Medical Sciences that show that alcohol consumption is not good for Indians. In India, most people drink whiskey, and the pattern of drinking is such that they drink a lot on a particular day and then don’t drink any alcohol for the next 5 – 6 days. This is binge drinking. The person may say he is a social drinker, but they don’t realise that they are actually consuming a lot of calories in the form of alcohol and also eating fatty food with it. And this is seen across classes.

If you have to choose an alcoholic drink, you could have a glass of wine [150ml]. But that does not mean that wine should be had everyday simply because it has health benefits. Or people who don’t drink alcohol should now start having wine. That is never recommended.

What are your views on marathon running?

If you are very well-trained and athletic, you can do marathons but don’t get out of your chair 15 days before the date of the marathon and decide that you will run because your colleague is running. I am a critic of marathons and I think it has become a fad now. To me, marathon running is not meant for two-legged animals. We have evolved in a way that our bodies are no longer suited to running. Every Mumbai Marathon has at least one person dying and for that family, it’s a permanent loss.

Just this past January, a guy training for the marathon went to the neurologist with jaw pain. He was brought to me and we found a critical 90% blockage in his arteries. Had he run the marathon five days later, it could have been fatal. Marathon running is not everybody’s cup of tea, and especially not of young, unfit Indians. There is an article in The New England Journal of Medicine that says that the incidence of deaths is low in the more than million marathon runners they have accounted for. But those deaths are due to abnormal congenital heart diseases [like hypertrophic cardiomyopathy etc] and not the kind that occur due to blocked coronary arteries that we see in here India every year. The issues people face after the marathons are not reported either. My advice: get in shape first before running marathons.

This was first published in the April 2014 issue of Complete Wellbeing.