ARE INDIANS DESTINED TO DIE YOUNG?
When I pose this question to myself, my students and my colleagues, the answer is a resounding and collective “Yes”. To top the misery, many of them would turn around and ask me “Why not?
It makes me sad, worried, perplexed and searching for more answers. Indians form the highest risk race in the entire mankind in terms of predisposition to cardiovascular disease.
Cardiovascular disease is the no 1 killer (>25% deaths )worldwide for the past 20 years now, far more than Cancer, HIV or TB or any other infections. It will be the no 1 killer in India in two years time.(.>28% deaths)
What is more unnerving is the comparison of the risk of Indians as a race with any other race in the world. The average Indian risk is 20 times as compared to the Japanese (one), the Chinese( 3.3 times) and the Americans (5 times) .
This is despite the fact, Japanese have the highest incidence of Hypertension especially in view of their ageing population. The Chinese are The Chain smoking Race, if such term ever exists. The Americans are in the midst of an obesity epidemic which makes them the heaviest nation in the world literally.
The other bigger tragedy is it affects the most vital and the most productive age group. The Young. The general impression amongst all physicians across the country is that our patients are a decade younger than their western counterparts. The results are even more startling. 40% below 45 years and 50% below 50 years.
The urban rural divide is observed in the double incidence in urban areas, but also highlights the fact that even rural areas are not spared. i.e A villager in Villupuram is still at a higher risk than a New Yorker.
Another commonly held myth in the US and even in India is the belief that coronary artery disease is a disease of the rich and affluent class. The misery is it is a disease of the masses and not the classes as we would wish to believe. In fact in US, being poor is a high risk attribute since you can afford healthy food or lifestyle.
Then the obvious question is why do we suffer the most ? we never smoke like the chinese and are not as obese as the Americans and yet are singled out for maximum punishment.
The answers are multifaceted and reflect our sorry state in general.
1) Genetics : we seem to have inherited what is called the “ Thrifty Gene”. The hypothesis is that people born in the 1950s- 60s developed a gene to handle with the metabolic crisis of unsatiated need by hoarding. This led to an abnormal handling of energy from food leading to obesity and metabolic syndrome at routine levels of food intake.
2) Diabetes : If there is one epidemic which is eating away the health of our nation exactly like corruption eats into our economy, it is diabetes. We have the dubious distinction of being the Diabetes Capital of the world i.e we have the highest incidence of diabetes as a race only less than an obscure race called Pima Indians. Diabetes and Heart Disease have always had a Shakuni- Duryodhana kind of bonding with equally deleterious effects
3) Smoking: Though we smoke less than rest of the world , our consumption of non smoke tobacco is among the highest in the world and it also includes a big chunk of women. So we cannot escape from the clutches of the ill effects of tobacco.
4) Cholesterol : High levels of bad cholesterol is not very common in our country. The unfortunate aspect is we have the worst combination of cholesterol in the world possible. Low bad cholesterol (LDL) with very low good cholesterol(HDL) with high triglycerides which makes it most difficult to treat with presently available drug options.
5) Abdominal Obesity : we are notorious in developing a paunch around our tummy as compared to the rear or back. Why we show such predisposition and why such fat distribution contributes to heart disease are poorly understood concepts and subject of intense research.
6) Psychosocial Stress : If there is one risk factor which cannot be quantified in a tangible measure, it is the amount of stress a person is subjected to. Across urban and rural areas, Indians are leaders in the amount of stress we unwittingly subject ourselves to in our lifetime.
7) Diet : Probably the most hyped and yet the most poorly understood risk factor in the cardiovascular disease context is the diet. Is McDonaldisation of any country directly proportional to the Heart Disease incidence ? The answer is yes. Is it responsible for India’s epidemic. The answer is No. It may seem funny but it is the truth. The avoidance of traditional home made foods, the fast food culture and the increasing non affordability of fruits and vegetable contribute in equal measure. Some food traditions like the Jain, Hyderabadi, kerala based foods are by nature gruel provoking.
8) Exercise. We are the sloth nation of the world best exemplified by our Olympic performances every four years. The average upwardly mobile urban Indian hardly does any physical activity in a day. Increased machination and automation has resulted in a nationwide dearth of any form of physical activity by all sections of society.
9) The only risk factors in which we are not world leaders is Hypertension and Alcohol. Unfortunately even in that our scenario is not encouraging. Although our hypertension incidence is on par with rest of the world, diagnosis, treatment, adequacy and compliance to treatment levels are abysmally low and pathetic. We are neither beer guzzlers like the British nor wine connoisseur like the French but are binge drinkers and poor metabolizers. i.e our livers genetically handles alcohol loads poorly than other races.
10) The muck gets worse than what we can imagine, when we assess the coronary artery disease pattern in our patients. Our patients have more extensive disease and more diffuse disease than Western patients. Also our average coronary artery size is <3.0 mm making it even more difficult to intervene with poorer revascularization results
Is there no way out? Am I a doomsday prophecy proponent?
We together can make a change if we want. We need collective action from all sections of society and government to make it happen. Some of the measures which may make a positive impact include the following
a} Fight of the Bulge:
It should start from birth and not from 40 years. Childhood obesity should be the target of policy makers, doctors, schools and parents alike. A chubby child is not a sign of health and prosperity but a disaster waiting to happen.
B} Exercise as a culture:
It is not a fad or style statement, but a basic approach of life. Every body from government to institutions especially schools should promote exercise as a habit. Small things like a dedicated cycle path on arterial roads, incentives for using a cycle to work, promoting use of stairs, go a long way in achieving this goal.
C} Policy decisions:
Small measures like a fat tax,(i.e Value added tax = fat content %), salt tax based on sodium content and banning Fastfood joints in the vicinity of educational institutions (i.e TASMAC, Cigarette shops and KFC should carry the same restrictions) are essential first steps. Mandatory medical check up for all forms of employment could be a first step for early screening for risk factors.
D} Diabetes Drive:
If we as a nation show more alacrity towards prevention, early detection and aggressive treatment of diabetes, than what we showed for Polio, we would be in better shape. Dr.Man Mohan Singh is one of the prime examples of how diabetes leads to repeat interventions and surgery.
E} CM Health Insurance
The CM Health Insurance has benefitted more than a lakh people suffering from cardiovascular disease by funding their interventions and surgery. It has made high end cardiac care available to the impoverished classes. Spending crores of rupees on intervention is justified but an iota of that amount should be earmarked for preventive cardiology aspect. Schemes like free cardiac screening camp for all Health Card Holders could be a first step in the right direction.
When things like AmmaUnavagum have captured the imagination of the masses in providing wholesome nutritious food, it makes us thing big and dream grander. It envisages health care centres dedicated to Preventive Cardiology to provide holistic care incorporating all elements of Indian Medicine including yoga, meditation. They can also take public education and awareness initiatives targeting healthy lifestyle habits, organ donation
We need to unite as a nation, fight like an army and save the Nation’s youth.
We need to modify Swami Vivekananda’s quote and pledge “ Arise, Awake and stop not till we make ourself a fit and healthy nation”