the empidemic of heart disease needs to be controlled

1. Emerging Lifestyle and
Cardiovascular Disorders
Dr. Ashwani Mehta,
Senior Consultant Cardiologist
Dharma Vira Heart Centre
Sir Ganga Ram Hospital
New Delhi

2. 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

3. Life Style Associated diseases
• Coronary Artery disease
• Cerebrovasular disease
• Peripheral Vascular disease
• Obesity
• Hypertension
• Diabetes
• Cancers
• Osteoporosis

4. Why is CVD treatment important ?
• 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.

5. Leading Cause of morbidity and
mortality

6. International CHD mortality trends
in men, 1968-2003
Source:BHF Heartstats (WHO statistics Men aged 35 - 74, Standardised)

7. 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%)

8. Rapid Rise of Lifestyle related
diseases in India ?

9. 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.

10. Mismatch between our modern diet and
lifestyle

11. 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.

12. 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).

13. Heart Disease in Indians
(International Comparative Data)
3x USA
6x China
20 x Japan
12
10
8
6
4
11
2 10.2
2.5 9.6
0
FHS U.S. CADI U.S. Delhi India Chennai India

14. GENETIC FACTORS in INDIANS??

15. 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

16. Obesity
Atherogenic diet
Inactivity
“French Paradox”

17. India: A Capital of Diabetes
Estimated number of diabetic subjects in India.
Indian J Med Res 125, March 2007, pp 217-230

18. INTERHEART Study ”nine potentially modifiable risk
factors account for over 90% of the risk of an initial acute myocardial
infarction” Population attributable risk factors
Smoking
Hypertension
Lipids (ApoB/A1 ratio)
Abdom obesity
Diabetes
Fruit & Veg
Alcohol
Exercise
Psychosocial
Other
Salim Yusuf et al . Effect of potentially modifiable risk factors associated with myocardial infarction in
52 countries (the INTERHEART study). Lancet 364 9437 11 Sept 2004

19. INTERHEART Study ”nine potentially modifiable risk
factors account for over 90% of the risk of an initial acute myocardial
infarction” Population attributable risk factors
Smoking
Hypertension
Lipids (ApoB/A1 ratio)
Abdom obesity
Diabetes
0%+ Fruit & Veg
ins 5
IET
expla
D death
s
Alcohol
CHD Exercise
Psychosocial
Other
Salim Yusuf et al . Effect of potentially modifiable risk factors associated with myocardial
infarction in 52 countries (the INTERHEART study). Lancet 364 9437 11 Sept 2004

20. Progression of Atherosclerosis
Healthy “Fibrofatty” Early Vulnerable Stable plaque
artery stage lesion plaque
teenager Intima thickens, 50 year old
atheromatous gruel
forms under cap
Lumen maintained Lumen narrows

21. How Does a Heart Attack Occur?

22. Dietary Factors

23. What is cholesterol ?
• 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.

24. Types of cholesterol
Lipoproteins- 4 main classes
• Chylomicrons
• Very low density lipoproteins (VLDL)
• Low Density Lipoprotein (LDL)
• High Density Lipoprotein (HDL)

25. Good vs Bad
• 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%

26. 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.

27. The facts about Fat
• 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

28. Types of 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.

29. What are polyunsaturated Fats ?
• 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.

30. Monounsaturated 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

31. Trans fatty acids
• 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

32. What about Omega 3 ?
• 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

33. Smoking

34. Smoking is the leading cause
of preventable death

35. 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.

36. Smoking Is Related to Many
Illnesses:
• Respiratory System • Damages
• Heart and Developing Fetus
Circulatory System • Facial Wrinkling
• Strokes
• Eyes and Vision
• Cancer
• Osteoporosis

37. LACK OF PHYSICAL ACTIVITY
36% OF DEATHS
FROM CAD IN MEN
AND
38% IN WOMEN ARE
D/T LACK OF
PHYSICAL ACTIVITY

38. Effects of Exercise on Heart Disease Risk
0%
-10%
-20%
-30%
Age
-40%
Reduction CHD Risk
-50%
-60%
Exertion
-70%
-80%
-90%
Frequency
-100%
Daily Walking Daily Walking Heavy Exertion Heavy Exertion
Midde-Aged Elderly 1-2/week 5-7/Week
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

39. Exercise modern Style

40. How much sooner does obesity give you a
heart attack?
74
72
70
68
Age (Years)
66
64
62
60
58
56
Normal Overweight Obese
Al Suwaidi J, et al. Clin Card 8/01

41. Fat Topography Subjects
Intramuscular
Subcutaneous FFA*
TNF-alpha*
Leptin*
Intrahepatic IL-6 (CRP)*
Tissue Factor*
PAI-1*
Intra-
abdominal Angiotensinogen*

42. Waist Circumference

43. 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)

44. Prevention of CVD
Managing the risk factors

45. Need of the hour..
– Education regarding the risk factors
– Lifestyle therapy
– Lipid lowering
– BP lowering
– Measures to improve treatment compliance

46. Cigarette Smoking Recommendations
Goal: Complete Cessation and No
Exposure to Environmental Tobacco
Smoke
•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.

47. How can you stop CVD ?
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)

48. ATP III Dietary Recommendations
Nutrient Recommended Intake
Saturated fat* <7% of total calories
Polyunsaturated fat Up to 10% of total calories
Monounsaturated fat Up to 20% of total calories
Total fat 25%–35% of total calories
Carbohydrate (esp. complex carbs) 50%–60% of total calories
Fiber 20–30 g/d
Protein ~15% of total calories
Cholesterol <200 mg/d
*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.
ATP=Adult Treatment Panel
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in
Adults. JAMA 2001;285:2486-2497.

49. Dietary guidelines
• 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.

50. 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.

51. 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

52. 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”

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

54. Trans Fat & CAD
 Replacing 2% of Trans fat, lowers the Risk of Heart disease by 53%.
 Avoid over heating & reuse of oil

55. A Comparison of Cooking Fats
Olive oil 77% 9% 14%
Peanut oil 49% 33% 18%
Corn oil 25% 62% 13%
(Mustard)
Soyabean oil 24% 61% 15%
Sunflower oil 20% 69% 11%
Saffower oil 13% 77% 10%
(Kardi)
Butter / Ghee 28% 3% 69%
(Coconut / Palm)
Monounsaturated Fatty Acids Polyunsaturated Fatty Acids Saturated Fatty Acids (SFA)
(MUFA) (PUFA) q Increases levels of ‘bad’
q Protects ‘good’ cholesterol (HDL) q Reduces levels of both ‘good’ (LDL) cholesterol
and reduces the level of ‘bad’ (HDL) and ‘bad’ (LDL cholesterol
cholesterol (LDL)
q increases the risk of
q Oxidises readily cardiovascular disease
q reduces the risk of heart
disease and diabetes q Breaks down into potentially toxic
substances during cooking

56. Physical Activity Recommendations
Goal: 30 minutes 7 days/week,
minimum 5 days/week
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

57. • 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..
Anders Grøntved (University of Southern Denmark, Odense

58. Comparison of Exercise and Antidepressants
25
Beck’s Depression Index
20
15
Baseline
10 16 Weeks
5
0
Medication Exercise
Blumenthal JA et al, Arch Intern Med 1999;159:2349

59. 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

60. Weight
Goal: BMI 18.5 to 24.9 kg/m2
Waist Circumference: Men: < 40 inches Women: < 35 inches
• Less than 18.5 • Under weight
• 18.5-24.9 • Normal weight
• 25-29.9 • Overweight
• 30 and above • Obese
*BMI is calculated as the weight in kilograms divided by the body
surface area in meters.

61. 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

62. 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

63. Obesity and Dieting Facts
♥ 3500 cal = 1 pound weight
♥ 1 mile = 100 cal
♥ Δ 100 cal/day = 10 pound/year

64. 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

65. Remember – we are predisposed
3x USA
6x China
20 x Japan
12
10
8
6
4
11
2 10.2
2.5 9.6
0
FHS U.S. CADI U.S. Delhi India Chennai India

66. Why are portion sizes important?
Eat less, Live long
20 Years Ago Today
210 Calories How 610 Calories are
many calories
in these fries?
Calorie Difference: 400 Calories
How to burn* 400 calories:
Walk 2 hr 20 Minutes
*Based on 130 pound person

67. Why is eating “fast food” similar to smoking 2
cigarettes?
10% SHAM
8%
* P <0.05
6%
ONE CIGARETTE
4%
Egg McMuffin, 2%
Sausage McMuffin,
2 Hash Browns
0%
0 2 4 6
HOURS
Vogel RA et al, Am J Cardiol 1997;79:350 LeKakis JP et al, Circulation 1996;97:I-355

68. Statins and CAD
• Lots of evidence
• Safe
• Easily available
• Need of the hour

69. Be Careful with Alcohol

70. Lack of Sleep Causes
• Difficulties with memory and learning
• Increased irritability
• Accidents
• Illness
• Lack of energy
• Stress
• Weight gain
• Rapid aging

71. Obstructive 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

72. Stress Reduction
• exercise regularly • get a pet, especially a dog
• do daily enjoyable activities
• get sufficient sleep
• take a vacation
• develop close relationships • develop spirituality
• laugh • volunteer
• try meditation
• touch and be touched by
• stop watching television
people
• stop watching television

73. Heart Attack
• Common Myths – Gas / cervical
• ECG can miss
• Earliest treatment-Open artery as soon as
possible
• Time is muscle – saves lives

74. TIME IS MUSCLE
PRE
POST
MISSION TO SAVE

75. Is Life style change enough?
Coronary Arteriography
8/25/97 10/19/99

76. 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

77. Heart Disease in Indians
14
12
10
Growing
8
6 but
4 preventable Epidemic !!
2
0
1960 1962 1968 1990 1994 2001 2015

78. life style the real culprit ?

79. Good Health to You!