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Preventing Heart Disease: Know Risk to No Risk
Dr K Srinath Reddy
The World Health Organization, World Heart Federation and the World Bank are all unanimous in their verdict – India is suffering huge economic burdens due to heart and blood vessel diseases (principally heart attacks and strokes). Over 3 million Indians presently lose their lives annually due to these diseases and the toll is expected to rise to over 5 million deaths in 2020.

Nearly half of these deaths occur under the age of 70 years. India lost 9.2 million potentially productive years of life due to heart disease related deaths occurring prematurely in the age group of 35-64 years in 2000. This loss will reach 17.9 million years by 2030. In comparison with USA, India’s loss was 570% more in 2000 and will be 940% more in 2030. A country which wishes to position itself as a major economic power in the 21st century cannot afford such hemorrhaging of precious human resources in the productive prime of life.

While socio-economic transitions (living habits altered by urbanization and globalization) and demographic transitions (increasing life expectancy, with more deaths occurring at older ages) contribute to the rise in the risk of heart diseases, much of the risk is avoidable. Many of the deaths due to heart attacks and strokes can be prevented or at least postponed to a much older age, with very few succumbing before 80 years.

Our ability to prevent the onset of these diseases and slow down their progression depends on the knowledge of the factors which increase or decrease the risk of developing disease. Extensive scientific evidence, from several countries, clearly demonstrates that behavioural risk factors like an unhealthy diet, physical inactivity, tobacco consumption and stress lead to elevation of biological risk factors like blood pressure cholesterol (and other harmful fats) and sugar. Increased body weight and an expanding waist circumference mediate between these behavioural and biological risk factors.

All of these risk factors operate along a continuous risk gradient – it is better to have a blood pressure of 120/80 than 130/85 which is preferable to 140/90 or more. Since the mid-range values occur in maximum numbers of people in any population, more heart attacks arise from the many people who have modest elevations of risk factors than in the  few who have very high levels (akin to C K Prahlad’s book Base of the Pyramid). When many risk factors co-exist, the risk is additive. Thus, many people with ‘mild’ elevations of several risk factors end up with a high risk of heart attacks. It is important for doctors to do a full risk profiling of all major risk factors to estimate the composite or ‘absolute’ risk of developing a heart attack or stroke in the near future. Based on that estimate of individual risk, decisions on lifestyle advice and drug therapy can be customized. Every contact between any healthcare provider and a person seeking healthcare must be utilized for risk assessment and ‘missed opportunities’ for early detection must be minimized in primary healthcare.

People too must recognize that many of these risk factors can be prevented or reduced by exercising intelligent choices. Keeping away from tobacco greatly reduce the risk of a heart attack while smoking greatly magnifies the risk posed by high blood pressure or diabetes. Reducing salt consumption reduces the number of deaths due to strokes by 22% and those from heart attacks by 16%. Avoiding unhealthy fats, reducing refined sugars and increasing the intake of fruit and vegetables further reduce the risk substantially. Physical inactivity increases the risk by 1.5 times while even moderate activity, regularly performed, is very protective. With such healthy habits, risk factors such as body weight, belly fat, blood pressure, blood sugar and blood fats can be kept under check. The World Health Organization believes that 75% of the risk can be prevented by such measures.

It is also useful for adults, especially those with a family history of premature heart disease, to undertake regular check-ups for identification of risk factors and estimation of the ‘absolute’ risk. ‘Knowing the risk’ means that the person concerned as well as the physician can take effective measures to reduce it. Through a judicious combination of lifestyle measures (always needed) and drugs (whenever needed), much of the risk can be avoided or reversed. It is then very much possible to proceed to a ‘No Risk’ status. That is why the theme for the World Heart Day adopted in 2008 - “Know Your Risk” is very relevant.

Dr. K. Srinath Reddy is President of the Public Health Foundation of India (PHFI) and Professor of Cardiology at the All India Institute of Medical Sciences (AIIMS). He is also the President of the World Heart Federation’s Advisory Board.