Emerging Lifestyle and Cardiovascular Disorders

Dr. Ashwani Mehta, Senior Consultant Cardiologist

Dharma Vira Heart Centre

Sir Ganga Ram Hospital

New Delhi

leading cause of death -worldwide

Coronary disease 7.2 million

Cancer 6.3

Cerebrovascular disease 4.6

Acute lower respiratory tract infections 3.9

Tuberculosis 3.0

COPD (chronic obstructive pulmonary disease) 2.9

Diarrhoea (including dysentery) 2.5

Malaria 2.1

AIDS 1.5

Hepatitis B 1.2

Life Style Associated diseases

• Coronary Artery disease• Cerebrovasular disease• Peripheral Vascular disease• Obesity• Hypertension• Diabetes• Cancers• Osteoporosis

• Most common cause of death

• Kills more people in developed countries than the next

leading 6 causes (including cancer)• Worse in low-income and middle-income countries.• 4/5 of all CVS events occur in these parts of the world. India

is no exception.

Why is CVD treatment important ?

Leading Cause of morbidity and mortality

International CHD mortality trends in men, 1968-2003

Source:BHF Heartstats (WHO statistics Men aged 35 - 74, Standardised)Source:BHF Heartstats (WHO statistics Men aged 35 - 74, Standardised)

CAD in India - An Emerging Epidemic

• 10% of adult population – 6 crores

• 15-16x105 – die annually because of Cardiovascular disease

• By 2010 – maximum no. of CAD cases in South Asia (60%)

Rapid Rise of Lifestyle related diseases in India ?

Evolution

• Our genetic make-up has evolved through millions of years -determines our nutrition and activity

• Genome has remained primarily unchanged - agricultural revolution 10,000 years ago.

• Our diet and lifestyle has become progressively divergent from those of our ancestors.

Mismatch between our modern diet and lifestyle

Evolution of Nutrition and Lifestyle:

Ancestors - ate a high fiber,predominantly plant based

• Foliage, leafy vegetables, fruits, seeds and nuts• High in plant sterols, vegetable protein, a variety of

phytochemicals and antioxidants.• Such a diet would result in low cholesterol and oxidative.

still eaten by surviving great apes/tribals.

Socially we are people of the 21st century but genetically we remain citizens of the Paleolithic era (marked by the agricultural revolution 10,000 years ago).

Heart Disease in Indians(International Comparative Data)

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FHS U.S. CADI U.S. Delhi India Chennai India

3 x USA6 x China20 x Japan

GENETIC FACTORS in INDIANS??

What is the cause of Increase Heart Attack in Indians

1. Increase Longevity

2. Better control of Diseases

- Infections (Diarrhea, TB) & Nutritional

3. Increase in Risk Factors & Exposure like HT,DM,lipids

4. Rapid urbanization, industrialization – lead to affluence & unhealthy life style

- Smoking, Alcohol

- Sedentary habits

- Unhealthy food

5. Genetic Predisposition – Metabolic Syndrome

“French Paradox”

Obesity

Atherogenic diet

Inactivity

India: A Capital of Diabetes

Estimated number of diabetic subjects in India.

Indian J Med Res 125, March 2007, pp 217-230

Smoking

Hypertension

Lipids (ApoB/A1 ratio)

Abdom obesity

Diabetes

Fruit & Veg

Alcohol

Exercise

Psychosocial

Other

  INTERHEART Study ”nine potentially modifiable risk factors account for over 90% of the risk of an initial acute myocardial infarction” Population attributable risk factors

Salim Yusuf et al .Salim Yusuf et al .  Effect of potentially modifiable risk factors associated with myocardial infarction in Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study). 52 countries (the INTERHEART study). LLancet ancet  364  9437   11 Sept 2004 364  9437   11 Sept 2004

Smoking

Hypertension

Lipids (ApoB/A1 ratio)

Abdom obesity

Diabetes

Fruit & Veg

Alcohol

Exercise

Psychosocial

Other

Salim Yusuf et al .Salim Yusuf et al .  Effect of potentially modifiable risk factors associated with myocardial Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study). infarction in 52 countries (the INTERHEART study). LLancet ancet  364  9437   11 Sept 2004 364  9437   11 Sept 2004

DIET DIET explains explains

50%+ CHD deaths

50%+ CHD deaths

 INTERHEART Study ”nine potentially modifiable risk factors account for over 90% of the risk of an initial acute myocardial infarction” Population attributable risk factors

Progression of Atherosclerosis

Healthyartery

Earlylesion

Vulnerableplaque

Stable plaque“Fibrofatty” stage

Lumen maintained

Intima thickens, atheromatous gruel

forms under cap

Lumen narrows

teenager 50 year old

How Does a Heart Attack Occur?

Dietary Factors

• Everybody needs cholesterol, it serves a vital function in the body.

• It is a component of the nerve tissue of the brain and spinal cord

• A major component of the plaque that clogs arteries.

What is cholesterol ?

Lipoproteins- 4 main classes• Chylomicrons

• Very low density lipoproteins (VLDL)• Low Density Lipoprotein (LDL)• High Density Lipoprotein (HDL)

Types of cholesterol

• LDL is known as bad cholesterol. It has a tendency to increase risk of CHD.

• LDL’s are a major component of the atherosclerotic plaque that clogs arteries.

• Levels should be <130– Indians < 70mg%

Good vs Bad

• HDL is known as the good cholesterol.

• It helps carry some of the bad cholesterol out of the body.

• Levels should be >35.

• High levels of HDL >60 can actually negate one other risk factor.

Good vs Bad

• Certain fats are essential for good nutrition and health.

• Fats provide essential fatty acids which the body can’t manufacture.

• Act as insulators to maintain body temperature.

• Improve the palatability of food and promote digestion.

• Greatest energy output per gram of any food source.

• Carry fat soluble vitamins- A,D,E, and K

The facts about Fat

• Saturated fats- basically means the fat is saturated with hydrogen, they are solid at room temperature. Examples are ghee and butter.

• Why are they bad for you? They increase levels of LDL , decrease HDL and increase total cholesterol.

Types of Fat

• They are unsaturated fats which are liquid at room temperature and in the refrigerator.

• Why are they good for us?

• They help the body get rid of newly formed cholesterol.

What are polyunsaturated Fats ?

• They are liquid at room temperature but start to solidify in the refrigerator.

• Decrease total cholesterol and lower LDL levels.• Example: Mustard, Soyabean, Canola Oil

Monounsaturated Fats

• Trans fatty acids

• They are unsaturated fats but they tend to raise total and bad cholesterol.

• Where do you find them?

• In fast-food restaurants, Commercial baked goods. Examples: doughnuts, potato chips and samosa etc

Trans fatty acids

• Type of polyunsaturated fat.

• Consistently lowers serum triglycerides and may also have an effect on lowering blood pressure.

• Found in oily fish such as salmon, tuna, and herring.

• Is available as a supplement.• Example: Olive Oil

What about Omega 3 ?

Smoking

Smoking is the leading cause of preventable death

About 430,000 Americans die each year from smoking related

illnesses Imagine 4 jumbo jets each carrying 400 persons

crashing each day. This is how many people die each year from

smoking related illnesses.

Smoking Is Related to Many Illnesses:

• Respiratory System• Heart and

Circulatory System• Strokes• Eyes and Vision• Cancer• Osteoporosis

• Damages Developing Fetus

• Facial Wrinkling

36% OF DEATHS FROM CAD IN MEN

AND 38% IN WOMEN ARE

D/T LACK OF PHYSICAL ACTIVITY

LACK OF PHYSICAL ACTIVITY

-100%-90%-80%-70%-60%-50%-40%-30%-20%-10%

0%

Daily WalkingMidde-Aged

Daily WalkingElderly

Heavy Exertion1-2/week

Heavy Exertion5-7/Week

Age

Exertion

Frequency

Red

uct

ion

CH

D R

isk

Mittleman MA et al, N Engl J Med 1993;329:1677 Rodriquez BL et al, Circulation 1994;89:2540 Hakim AA et al, Circulation 1999;100:9

Effects of Exercise on Heart Disease Risk

Exercise modern Style

56

58

60

62

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70

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74

Normal Overweight Obese

Age

(Y

ears

)

Al Suwaidi J, et al. Clin Card 8/01

How much sooner does obesity give you a heart attack?

Fat Topography Subjects

Intramuscular

Intrahepatic

Subcutaneous

Intra-abdominal

FFA*TNF-alpha*Leptin*IL-6 (CRP)*Tissue Factor*PAI-1*

Angiotensinogen*

Waist Circumference

Resulting Clinical Conditions:

• Type 2 diabetes

• Essential hypertension

• Polycystic ovary syndrome (PCOS)

• Nonalcoholic fatty liver disease

• Sleep apnea

• Cardiovascular Disease (MI, PVD, Stroke)

• Cancer (Breast, Prostate, Colorectal, Liver)

Managing the risk factors

Prevention of CVD

Need of the hour..

– Education regarding the risk factors– Lifestyle therapy– Lipid lowering– BP lowering– Measures to improve treatment compliance

Goal: Complete Cessation and No Exposure to Environmental Tobacco

Smoke

Cigarette Smoking Recommendations

•Every tobacco user to quit.

• Counseling and developing a plan for quitting.

•Special programs, or pharmacotherapy (including nicotine replacement and bupropion.

•Avoidance of exposure to environmental tobacco smoke at work and home.

Diet and Nutrition

• Eat a variety of fruits and vegetables every day. ( 5 servings - they are naturally low in fat and high in vitamins and minerals)

• Eat a variety of grain products ( 6 a day)

How can you stop CVD ?

*Trans fatty acids also raise LDL-C and should be kept at a low intake.Note: Regarding total calories, balance energy intake and expenditure to maintain desirable body weight.

<200 mg/dCholesterol

~15% of total caloriesProtein

20–30 g/dFiber

50%–60% of total caloriesCarbohydrate (esp. complex carbs)

25%–35% of total caloriesTotal fat

Up to 20% of total caloriesMonounsaturated fat

Up to 10% of total caloriesPolyunsaturated fat

<7% of total caloriesSaturated fat*

Recommended IntakeNutrient

Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001;285:2486-2497.

ATP III Dietary Recommendations

ATP=Adult Treatment Panel

• Choose fats with 2 gms or less of saturated fats

• Balance the # of calories you eat with the number of calories you use each day.

• Maintain a level of physical activity that keeps you fit and matches the # of calories you eat.

Dietary guidelines

• Limit your intake of foods high in calories and low in nutrition, including foods like soft drinks .

• Limit foods high in saturated fat, trans fat and cholesterol

• Eat less than 6 gms of salt a day

• Have no more than one alcoholic drink a day.

Dietary guidelines

Nuts & Heart Diseases

• Myth – Nuts are bad for heart & they increase cholesterol

• Fact - WRONG : In fact it is a complete & healthy food

Free from cholesterol

Monounsaturated Fats (MuFA), Protein, CHO,

Minerals, Vitamins, Iron, Calcium & Fiber

20-40 gm/day of Nuts reduces cholesterol

• Caution – Contains calories, can trigycerides,

Avoid in obese patients

Dairy Consumption & Heart Diseases

• Myth - Milk is essential & complete food for human beings

• Fact - WRONG. Only low fat milk is allowed

It contains - SAT.FAT & Cholesterol

Animal Protein - Casein - Cause of Allergy,

damages Heart Cell, Pancreas

Lactose Intolerance & Abdominal Disease

Spread of viral & bacterial disease

lack of ess. Amino acids, iron & Hormones consumption

• No Mammal Drinks others milk except human beings

• Good alternative source of Calcium are green veg.,Soya,Fruits,Nuts etc.

• Soya milk & its products are good substitute

Slogan – “One should drink milk till you drink your mother’s milk, after

that we have no right to drink others milk”

Fruits & Vegetables 5 servings of fruits & vegetables reduces heart attacks by 25-30%

Trans Fat & CAD

Replacing 2% of Trans fat, lowers the Risk of Heart disease by 53%.

Avoid over heating & reuse of oil

A Comparison of Cooking Fats77%

49%

25%

24%

20%

13%

28%

77%

69%

61%

62%

33%

9% 14%

18%

13%

15%

11%

10%

69%

Olive oil

Peanut oil

Corn oil(Mustard)

Soyabean oil

Sunflower oil

Saffower oil (Kardi)

Butter / Ghee(Coconut / Palm)

Monounsaturated Fatty Acids (MUFA)

Protects ‘good’ cholesterol (HDL) and reduces the level of ‘bad’

cholesterol (LDL)

reduces the risk of heart disease and diabetes

Polyunsaturated Fatty Acids (PUFA) Reduces levels of both ‘good’ (HDL) and ‘bad’ (LDL cholesterol

Oxidises readily

Breaks down into potentially toxic substances during cooking

Saturated Fatty Acids (SFA) Increases levels of ‘bad’ (LDL) cholesterol

increases the risk of cardiovascular disease

3%

Physical Activity Recommendations

Encourage 30 to 60 minutes of moderate intensity aerobic activity such as brisk walking, on most, preferably all, days of the week,

supplemented by an increase in daily lifestyle activities

Goal: 30 minutes 7 days/week,

minimum 5 days/week

Anders Grøntved (University of Southern Denmark, Odense

• Association between TV viewing and risk of type 2 diabetes, fatal or nonfatal cardiovascular disease, and all-cause mortality

• Meta-analysis of 8 studies

• Results - relative risks per two hours of TV viewing per day of 1.20 for type 2 diabetes, 1.15 for fatal or nonfatal cardiovascular disease, and 1.13 for all-cause mortality..

0

5

10

15

20

25

Medication Exercise

Baseline

16 Weeks

Bec

k’s

Dep

ress

ion

In

dex

Blumenthal JA et al, Arch Intern Med 1999;159:2349

Comparison of Exercise and Antidepressants

TV Viewing

• Influence Eating pattern in all specially children• Promote lethargy and couch potatoes• Waste time – already scarce • Exercise while watching TV • "Public-health messages recommend an

increase in physical activity

Weight

Goal: BMI 18.5 to 24.9 kg/m2

Waist Circumference: Men: < 40 inches Women: < 35 inches

*BMI is calculated as the weight in kilograms divided by the body surface area in meters.

• Less than 18.5

• 18.5-24.9

• 25-29.9

• 30 and above

• Under weight

• Normal weight

• Overweight

• Obese

Weight loss

• Initial goal -should be to reduce body weight by approximately 10 percent from baseline.

• Further weight loss can be attempted if indicated.

• Many approaches possible today

How to Lose Weight

• Drink diet; water is even better

• Start with a salad or soup

• Cut portion size in advance - “pepper half your pie”

• Stay away from “fast food”

• Walk more; watch less TV

3500 cal = 1 pound weight

1 mile = 100 cal

Δ 100 cal/day = 10 pound/year

Obesity and Dieting Facts

Adults Need 30-60 Minutes of Moderate Activity Each Day

• Moderate activity is one that requires as much energy as walking 2 miles in 30 minutes

Remember – we are predisposed

2.510.2

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FHS U.S. CADI U.S. Delhi India Chennai India

3 x USA6 x China20 x Japan

How to burn* 400 calories:Walk 2 hr 20 Minutes

20 Years Ago Today

210 Calories How many calories are in these fries?

610 Calories

Calorie Difference: 400 Calories

*Based on 130 pound person

Why are portion sizes important?Eat less, Live long

* P <0.05

Egg McMuffin, Sausage McMuffin,

2 Hash Browns

10%

8%

6%

4%

2%

0%

0 2 4 6

SHAM

ONE CIGARETTE

HOURSLeKakis JP et al, Circulation 1996;97:I-355Vogel RA et al, Am J Cardiol 1997;79:350

Why is eating “fast food” similar to smoking 2 cigarettes?

Statins and CAD

• Lots of evidence

• Safe

• Easily available

• Need of the hour

Be Careful with Alcohol

Lack of Sleep Causes

• Difficulties with memory and learning

• Increased irritability

• Accidents

• Illness

• Lack of energy

• Stress

• Weight gain

• Rapid aging

Obstructive Sleep Apnoea & HTObstructive Sleep Apnoea & HT

• 50% of OSA have HT

• 30% of HT have OSA

• Independent - age & obesity related

• Nasal C-PAP & wt reduction

• Prevents & treat HT

• exercise regularly

• get sufficient sleep

• develop close relationships

• laugh

• touch and be touched by

people

• get a pet, especially a dog

• do daily enjoyable activities

• take a vacation

• develop spirituality

• volunteer

• try meditation

• stop watching television

Stress Reduction

• stop watching television

Heart Attack

• Common Myths – Gas / cervical

• ECG can miss

• Earliest treatment-Open artery as soon as possible

• Time is muscle – saves lives

PRE

POST

TIME IS MUSCLE

MISSION TO SAVE

Is Life style change enough?Coronary Arteriography

8/25/97 10/19/99

Ways to Live to be 100

• Stay active - exercise regularily

• Be Close to nature

• Eat less meat, fat and sugar

• Get enough sleep

• Relax

• Get cancer screening

• Be an optimist

Growing

but

preventable Epidemic !!

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1960 1962 1968 1990 1994 2001

Heart Disease in Indians

2015

life style the real culprit ?

Good Health to You!