Debating India

HEALTH

Where Blood Runs Sicker

Smita MITRA

Monday 17 May 2004, by MITRA*Smita

India’s original sin: heart disease. We’re genetically more predisposed to it than any.

Ten-year-old Nazia Samreen thought she was dying. Sweating profusely, with severe chest pains racking her small body, she took shallow breaths in the ICU at Hyderabad’s Mahavir Hospital. An angiography revealed a shocking result: 99 per cent of her main left artery was blocked, a condition more likely to be found in an obese, ungainly 40-year-old.

Nazia’s would have been a freak case in the West. But Dr Rajendra Kumar Jain, whose intervention saved her life, says her story is a warning for any one of the billion-plus ethnic Indians worldwide. Says he: "It doesn’t matter whether you migrated from here a hundred years ago or still live here."

"India adds 45% to the world coronary burden now." And it could cross 50% by 2020.

Jain is just one of the several doctors who are concerned about new research in India and abroad that clearly show Indians are the most vulnerable people on earth to heart attacks, angina and plaque formation in the arteries,

clubbed generically under CAD or coronary artery disease. And the risk factors aren’t limited to "sedentary lifestyle, smoking and obesity", mantras we have all heard before.

Studies that compare the risks between different ethnic groups show just how much more danger Indians face. The findings of Dr Enas A. Enas, director of the non-profit Coronary Artery Disease in Asian Indians Research Foundation, published in the Indian Heart Journal and based on studies in Canada, England, Singapore and South Africa (all countries with significant ethnic South Asian populations), show that Indian men and women consistently suffered higher CAD mortality rates than Whites, Chinese, Blacks and Malays.

The incidence of CAD is between two and four times as high for Indians than it is for Americans, Britons and other Asians like the Chinese. It also strikes us much earlier. A whopping 25 per cent of all heart attacks affecting people from the Indian subcontinent hit people under 40, a rarity in any other population.

Says Dr K. Srinath Reddy, head of the cardiology department at Delhi’s premier All India Institute of Medical Sciences: "Currently, the Indian subcontinent contributes 45 per cent of the global burden of CAD." Doctors fear the figure could cross 50 per cent by 2020.

A particular worry is that the incidence of CAD can’t just be explained through poor lifestyle behaviour. The problem is much deeper and harder to tackle. It’s in our genes. Says Reddy: "Our lifestyle only pulls the trigger on what our genes predispose us to do."

Indians are genetically predisposed to diabetes, a known precursor of CAD. "We have impaired glucose tolerance, which makes us diabetes-prone. Even borderline diabetes significantly ups CAD risk," Reddy explains.

He ticks off other offenders; our abysmally low hdl (good cholesterol that fights blockages) levels and high triglyceride counts. Worse, even our ldl (bad cholesterol) is nastier. Says he: "We have a relative excess of small, dense ldl particles, which are more effective in creating arterial blockages."

Dr Rajiv Agarwal, senior cardiologist at the Batra Heart Centre in Delhi, adds that these factors, along with our tendency to grow potbellies, make Indians the best CAD hosts in the world. And the risk factors (see box) tend to harm us more than they would, say, an American with the same lifestyle.

Agarwal talks about his youngest patient, Jitendra Dahiya, who had his first heart attack when he was just 22. "We had to do an angioplasty to clear the 90 per cent blockage in two of his three main arteries. He had none of the conventional risk factors like smoking or obesity and had a reasonably active life in Karnal, Haryana. Two years later, at 24, he had his second attack, after which we did a bypass surgery."

The news gets worse. Indian women, stripped of the traditional protection their gender provides because of genetic glucose intolerance, are as vulnerable to heart attacks as men.

Which is why Dr Ashok Seth, head of the cardiology department at Delhi’s Escorts Heart Institute, says, "Indians should take their hearts more seriously than any other ethnic group."

He pulls out a study by Enas. It lists the newly discovered villains-including lipoprotein (a) and homocysteine, an amino acid-we are destined to battle from birth. Both encourage sudden clot formations in our arteries.

"In general, the immediate cause of a heart attack is usually clots in the main arteries, not just blockage," explains Seth. But lipoprotein (a) doesn’t work alone. "African Blacks have elevated lipoprotein (a) levels, but are saved by their healthy hdl levels."

High homocysteine levels can fire off a heart attack by themselves. As with Nita Jain, 29, who had to be rushed to Escorts after a massive coronary one night. Her angiograph showed no significant blockage but her homocysteine level of 110 dwarfed the normal range of 10-15. Seth blames such abnormalities on folic acid deficiency: "Vegetables can maintain our folate levels, but Indian-style cooking-or over-cooking-robs us of any such nutrition."

Reddy also lays a lot of blame on dietary habits. "Look at Kerala. It uses coconut oil, possibly the worst cooking medium in the world. Earlier this was balanced by a fish-based diet. Now with fish being exported to the Gulf, people have shifted to meat. And CAD cases have skyrocketed."

In the past 30 years, the prevalence of CAD has risen from two to five per cent in rural India and has jumped from three to 10 per cent in urban India. Says Reddy: "It gives credence to the theory that even though we might be prone to CAD, we can avoid it if we are proactive."

Such advice stems from the fact that the hardening and clogging of arteries by fat deposits starts from childhood, not middle age, like we complacently imagine. And the dice is loaded against us from birth as a recent study conducted by Mumbai’s K.E.M. Hospital suggests. The study compared the birth weight and body composition of Indian and Caucasian babies. The results were startling. Indian babies, though smaller in all respects, were still "fat". They had generous subcutaneous fat deposits while their lean muscle and organ tissue growth was retarded.

Reddy explains the phenomenon. Says he: "If the mother’s diet isn’t balanced, as is the case in most Indian pregnancies, the foetus tries to adapt to the adverse conditions. These changes might help it survive in the womb, but work against the baby after birth."

"Low birth babies (under 2,500 grams) who catch up with normal weight patterns or become obese have higher diabetes and CAD risk. That is precisely why trends like childhood obesity need to be checked, while trying to improve average Indian birth weights (which currently languishes at 2,800 grams) by providing better prenatal care in India."

A solution based on gene technology isn’t coming anytime soon. "Our best bet is still to work on modifiable risk factors through a healthy, active lifestyle," reckons Reddy. He reasons that since the adverse effects of these factors are greater in Indians due to genetic predisposition, the benefits from modifying them would also be higher than in other populations. Which is a very sound reason to control smoking, high blood pressure, high cholesterol levels, saturated fat-rich diet and lack of physical activity.

P.S.

in Outlook India, Monday, May 17, 2004.

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