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C h a p t e r

3how do I Get a Grip of how

healthy My heart Is?

K e y M e s s a G e s

Eemotions, eating and exercise are the three things we should control to ensure a hearty health.

FFalse pretensions such as “my health needs no special care”, “I know what is best for my body” and “such a thing can never happen to me” are definite hurdles to preventing disease.

GGaining insights into the various risk factors is crucial to finding a permanent solution to lifestyle diseases.

Below is a conversation we had with Raj (55 years) and his wife Neela (52 years) who walked into our office recently.

Raj: Doctor, are you saying that my BP is high?Doctor: Yes Raj, your blood pressure (BP) has been consistently high on three

different occasions in the last three weeks. The normal BP for adults is 120/80 mmHg and yours is 150/96 mmHg. Has anyone ever told you that your BP was high?

Raj: No doctor.Doctor: Have you had a routine health check earlier or is this your first time?Neela: This is the first time doctor. I have been requesting him to get himself

checked for almost a year now. He has been very busy and has been postponing it.Doctor: Is that so? Raj, have you had any health issues in the past or are you

under any treatment?Raj: Not really doctor.Doctor: All right. So Neela, what prompted you to suggest a health check for Raj?

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Neela: Actually, doctor, he has been very worried about our daughters in the last year or so. The elder one is 28 years old and the younger is 26. They are both working in a company. He constantly worries about them and keeps tell-ing that they should get married before it gets too late. Both our girls are just not ready for it and have some great plans for their careers. I feel sorry that he is taking it too hard upon him. He has also been smoking more cigarettes than he normally does in the last few months. I am concerned that all this will affect his health.

Raj: Neela always lets them have their way doctor. I am very worried that they will remain single all their lives. I can’t even sleep well because this is constantly working in my mind. I try talking to them about it but they change the topic whenever I bring it up. They are still too immature to understand all this. They don’t realize that I am getting old. I will retire in three years’ time and would like to see them married and settled by then. When we were their age, we never even imagined about having our own way. My parents were the ones who decided when and to whom I should get married and what we should name our daughters. And I have no regrets. Why can’t our daughters blindly listen to my advice?

Another patient, Selva, aged 60 years, whom we had been treating for a condition called mitral stenosis (a disease of one of the valves in the heart), was doing well on medications. He had retired from serving the postal department two years ago and was having his heart functions assessed biannually. His valve function had remained unchanged since the previous assessment but his BP had shot up and his heart function had worsened.

Doctor: Selva, have you had any complaints in the last six months?Selva: Nothing major doctor. I just feel a bit more tired than normal and I get

more of the migraine attacks than before.Doctor: What do you think might be causing you to feel tired? Are you sleep-

ing well at night? Are you worrying about your health?Selva: I am not at all worried about my health doctor. In fact, I go for a walk

every other day and am eating a healthy diet. But there is something else that’s worrying me. I had invested all my savings in a private finance company at the time of my retirement with the hope that it will double quickly. Everybody at work had recommended that company as they were giving huge returns to all the investors. But to my disappointment, the news has gone from bad to worse in the last year. Now, I am not even sure if I will get back the money I had saved so meticulously. I was planning to close my home loan with the returns I got but it looks like I will not even be able to salvage my money. There are rumours that the company has gone bankrupt. Several others who have invested with them are also in the same boat as me. We are all trying to find out the truth of what is actually going on.

Doctor: I am sorry about that Selva. But if you’re eating and exercising right, how come you’ve added weight? Are you consuming a lot of alcohol?

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Selva: I think so doctor. I have been so worried and my family is also blaming me. When I drink I feel like my worries are not there anymore. What used to be a once-in-a-week drink has now become a daily thing. I am doomed. I have brought on this messy situation on myself and feel that things are getting completely out of control.

We know by instinct that the health of the individuals discussed above is deteriorating. In both cases, there has been a stressful trigger that has set in motion a cascade of problems. It is quite obvious that a better state of awareness about lifestyle diseases and their prevention, particularly about ways of managing stress, would have helped a great deal in avoiding such threats to health.

“How do I get a grip of how healthy my heart is?” is not a particularly difficult question to answer but the trick is there is no “one size fits all” response. However, understanding the key factors that determine your heart health is the first step in the journey towards a healthier heart and a happier life.

Risk FactoRs FoR cVDs

The causative factors or risk factors of CVDs have been under heavy scrutiny due to the steadily increasing incidence of these diseases since the early 1900s. The Framingham Heart Study, initiated in 1948, prospec-tively followed up a large group of people living in Framingham in USA and made some breakthrough findings on the major risk factors of CVDs. Further light was thrown on this aspect by the Interheart study, which included participants from 52 countries to show that the presence of psy-chosocial risk factors is associated with an increased risk of heart attacks. The risk factors are traditionally grouped into those that are not directly under our control (non-modifiable) and those that can be controlled (mod-ifiable) by us (Figure 10).

Non-modifiable Risk Factors

1. Advancing age: About 80% of people who succumb to CVDs are 65 years or older. However, the prevalence of the disease in the younger age groups is steeply rising. It is also imperative to realise that your biological age may be different from your chronological age, which is your actual age. The biological age is defined as the age that can be attributed to your body based on how healthy the organs are and how well they perform. In general, keeping the biological age lesser than the actual age is beneficial and is under our power. But alas, what we see often is that people in their 30s and 40s have a biological age of 60 or 70!

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2. Gender: Men have a greater risk of heart attack and stroke. Women have a low risk of CVDs during their reproductive years due to the protective effect of female sex hormones but are at increased risk after menopause. Also, women who have heart attacks are more likely than men are to die from them.

3. Genetic and racial predisposition: Children of parents with CVDs are at higher risk of developing the disease due to certain genetic factors they inherit. African Americans and a few other races have a higher incidence of hypertension and CVDs.

We cannot control our gender, age, genes and race; nevertheless, it is heartening to know that we can reduce and even nullify the effect of these fixed risk factors by paying attention to the risk factors that are under our control.

Modifiable Risk Factors

1. High Blood Cholesterol (Hypercholesterolemia)Cholesterol is an essential component of the cell membranes of humans

and animals. It also serves as a building block for the synthesis of steroid hormones, bile acids and vitamin D. Cholesterol comes from two sources:

RISK FACTORSOF CVD

Age

Diabetes

High BP

Gender

Obesity

HighColesterol

Race

Smoking

Alcohol

Genes

Inactivity

Stress

FiGuRE 10 Risk factors for cardiovascular diseases. Non-modifiable risk factors are shown as pink fixed boxes and modifiable risk factors as blue suspended boxes.

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the cholesterol our body synthesizes and the cholesterol in the food we eat. Liver and other cells in the body make about 75% of blood cholesterol. The other 25% comes from our daily consumption of food. Cholesterol is found only in animal products; plant based foods such as nuts and veg-etable oils are rich in phytosterol, a compound similar to cholesterol but which competes with cholesterol absorption during digestion and thereby lowers blood cholesterol levels. As blood cholesterol rises, so does the risk of blockage of blood vessels of the heart, brain and other organs. However, higher levels of ‘good’ cholesterol (HDL) and lower levels of both ‘bad’ cholesterol (LDL) and the ‘ugly’ component triglycerides are desirable to prevent heart attack and stroke. The optimal levels of cholesterol and its components in the blood are:

2. High Blood Pressure (Hypertension)Blood pressure (BP) refers to the force of blood flow exerted against the

walls of the arteries during the contraction (systolic BP) and relaxation (diastolic BP) of the heart. If the force on the arterial walls is too high over a prolonged period of time, that is, if the BP is higher than normal, the walls get stretched beyond the healthy limit leading to various problems like heart attack, stroke, loss of vision, kidney failure and erectile dysfunc-tion. It is because of the lack of symptoms during development of hyper-tension that it came to be called the “silent killer”.

Hypertension is of two types: primary hypertension and secondary hypertension. About 10% of cases of hypertension are caused by an under-lying problem such as chronic kidney disease, sleep apnoea, coarctation of the aorta, tumours or other diseases of the adrenal gland, alcohol addic-tion and thyroid dysfunction. This is called secondary hypertension and is treated by curing the underlying disease. Hypertension that arises dur-ing pregnancy is called pregnancy induced hypertension. It is a reversible cause of hypertension but can lead to serious complications for the mother and the fetus if left undiagnosed and untreated.

In the vast majority (90%) of people with hypertension there is no identifiable cause for the disease and they are said to have primary

• Total cholesterol: Less than 200 mg/dL ○ LDL (bad) cholesterol: Less than 100 mg/dL ○ HDL (good) cholesterol: 40 mg/dL and above for men, 50 mg/dL

and above for women ○ Triglycerides: Less than 150 mg/dL

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hypertension. The factors that are implicated in the causation of primary hypertension are:

This chart reflects blood pressure categories defined by the American Heart Association.

Blood pressure category Systolic mmHg (upper) Diastolic mmHg (lower)

Normal less than 120 and less than 80

Prehypertension 120–139 or 80–89

High blood pressure (hypertension) Stage 1

140–159 or 90–99

High blood pressure (hypertension) Stage 2

160 or higher or 100 or higher

Hypertensive crisis (Emergency care needed)

Higher than 180 or Higher than 110

3. Diabetes MellitusType 2 diabetes mellitus is the most common form of diabetes and is a

major risk factor for CVDs, peripheral arterial diseases, kidney diseases, nerve diseases and metabolic syndrome (we have elaborated on metabolic syndrome in the next chapter). A lack or inefficiency of the hormone insulin in diabetic individuals leads to accumulation of sugar in the blood in type 2 diabetes, which in turn damages various organs. Type 1 diabetes mellitus, on the other hand, refers to the total absence of insulin due to an autoim-mune process that destroys the insulin-secreting cells in the pancreas.

• Age: With advancing age, blood vessels become stiffer leading to raised BP.

• Gender: Men are more prone than women to have high BP. • Racial and genetic factors: Certain races develop hypertension early.

There is also a genetic predisposition to the disease. • Too much salt in the diet: This is an important contributor to hyper-

tension, specifically in the era of instant foods, premade sauces and packaged snacks. These are all examples of “salt shockers” and are loaded with salt content. If you have been just watching what you add from the salt-shaker in your kitchen and have been unaware of these off-the-shelf contributors, beware! The optimal salt intake per day for all of us is 1500 mg, which is about a teaspoon of salt in all that we consume taken together.

• Obesity, diabetes and physical inactivity are closely associated with hypertension.

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Type 2 diabetes is one of the lifestyle diseases that is rapidly gaining ground. Fasting blood glucose of 126 mg/dL or more denotes full-blown diabetes. Prediabetes is a condition where fasting blood sugar levels are higher than normal but have not quite reached the threshold for full-blown diabetes. Glycosylated haemoglobin or HbA1C is frequently mea-sured to diagnose diabetes and to check the control of sugar level in patients under treatment. A normal person without diabetes will have an HbA1C ranging from 4.5% to 6% and a person with uncontrolled diabetes for a long time will have a level above 8%. A target of 7% is commonly used to help titrate the dosage of antidiabetes drugs. The rule about HbA1C is higher the HbA1C, higher is the risk of developing complica-tions of diabetes.

Early recognition and management of the prediabetes stage is invaluable in the prevention of diabetes and its complications, particularly because this chronic disabling disease is affecting more and more youngsters. Both hyperglycaemia (>200 mg/dL) and hypoglycaemia (abnormally low level of blood glucose) are serious life-threatening complications that diabetes patients encounter.

4. Physical InactivityLack of adequate physical activity is a risk factor for heart attack. Sed-

entary lifestyle is by far the biggest setback of the modern mechanised world. Adding to it, crowded neighbourhoods, lack of green spaces and pollution of the environment make outdoor exercises a difficult task. Nevertheless, regular, moderate-to-vigorous activity, particularly aerobic activities like walking, jogging, swimming and cycling, are proven to con-trol high blood cholesterol, diabetes and hypertension and protect against CVDs. It is a good idea to supplement your workout regime with stretch-ing exercises and moderate weight training for overall health and fitness. The American Heart Association recommends the following weekly activ-ity levels:

• At least 30 minutes of moderate-intensity aerobic activity 5 days per week for a total of 150 minutes.

OR

• At least 25 minutes of vigorous aerobic activity 3 days per week for a total of 75 minutes; or a combination of the two.

AND

• Moderate to high intensity muscle-strengthening activity at least 2 or more days per week for additional health benefits.

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It ought to be highlighted here that there is no all or none law with regards to activity. Making small steps to begin with and gradually build-ing up on the exercise regime is definitely a good way to go for beginners.

5. ObesityThe looming public-health crisis of global obesity, referred to as “globe-

sity” in the modern era, is considered one of the biggest curses of the pres-ent times. An estimated half a billion or one in ten people worldwide are now considered obese. Being overweight is a direct consequence of the food consumed being disproportionate with the calories burnt. In short, overeating and eating the wrong kinds of food directly lead to obesity. Uncontrolled increase in weight results in obesity, which plays a key role in the causation of several health hazards including heart attack, stroke, diabetes, hypertension, arthritis and even some cancers.

Body mass index (BMI) is a number denoting the weight of an indi-vidual in relation to his/her height and is a good indicator of how healthy the weight is, irrespective of the body frame size. The formula for calculat-ing BMI is Weight (kilograms)/Height (meters)2. According to the World Health Organization, to achieve optimal health, the goal for individuals should be to maintain a BMI of 18.5–24.9 kg/m2. For Asians, however, the recommended upper limit of normal BMI is 23 kg/m2.11

Waist to hip ratio (smallest circumference of the natural waist or just above the navel/hip circumference measured at the widest part of the but-tocks or hip) is another useful marker of abdominal obesity. Men with a ratio above 0.9 and women with a ratio above 0.85 are said to be at a higher risk for CVDs.

Rarely, obesity can be the symptom of diseases of the endocrine glands such as thyroid dysfunction and adrenal gland disorders or the side effect of some medications.

6. SmokingSmoking tobacco in the form of cigarettes, bidis, cigars, hookahs and

chewed tobacco is a major preventable risk factor for CVDs and chronic respiratory disorders like asthma and bronchitis. Lung cancer is one of the most dreaded complications of smoking. The risks arise not only from direct tobacco consumption but also from exposure to second-hand smoke. In fact, children of parents that smoke are at an increased risk for sudden death dur-ing infancy and several health hazards as they grow up. The age of quitting smoking has a big impact on the survival prospects; those who quit before the age of 45 have the same survival rates as those who have never smoked.

7. Harmful Use of AlcoholBoth higher levels of alcohol consumption and binge drinking lead to

multiple adverse health and social outcomes, including hypertension,

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CVDs, cardiomyopathy, arrhythmia, cirrhosis of the liver, pancreatitis, fetal alcohol syndrome, violence, suicide and road traffic accidents. A significant proportion of deaths worldwide are attributable to hazardous and harmful drinking of alcohol.

8. StressManaging mental stress adequately seems to be the lynchpin in this

war against heart attack, stroke and all the other lifestyle diseases. The mechanisms by which stress and negative attitude affect our health has been discussed in detail in chapter 2; however, it has to be “stressed” again that uncontrolled stress leads to overeating, physical inactivity, smoking and alcoholism, all of which join forces to raise BP, increase blood sugar levels, lead to a disproportionate increase in body weight and result in the accumulation of bad cholesterol and a lowering of good cholesterol. Lack of sleep is yet another by-product of accumulating stress, so be weary. It is recommended that you get 7–8 hours of sleep each night for healthy functioning of the body and for adequate recovery and rejuvenation of the mind.

applying the Risk Factor Model to Real-Life scenarios

The risk factor model described above is certainly a lot of information for someone who has not had the opportunity to read or hear about it earlier. However, these conditions are so prevalent today that every one of us would have at least a relative or a friend or a colleague diagnosed with these diseases and trying to lead a normal life. Some of them might have had serious symptoms, which led to the diagnosis while others might have had a routine check unravel the abnormality. Similarly, the response in newly diagnosed individuals could be two-fold: a positive sense of responsibility to gather information about their condition and to control it, or a negative feeling of denial, helplessness or guilt.

The fact that there are lots and lots of readily available health portals these days makes it certainly easy to access information pertaining to a particular risk factor or disease. However, the news out there could be very confusing and misleading if there is no expert guidance from an experienced doctor or nurse. Moreover, knowing a lot of information is not the same as applying them to our daily lives and experiencing for ourselves the improvement in health.

Let us see how Raj, Neela and Selva, our real-life characters from earlier in this chapter, reacted to their health situations.

Raj and Neela were disappointed about the news they received about Raj’s health status. But they were open to discussion and were eager to get to the bot-tom of the hypertension issue. They understood that Raj had to control his stress,

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hypertension and smoking, which were important risk factors for heart attack. They were counselled on how their being worried about their daughters was not going to make things better for them but instead was alienating and distancing them from their children. In addition to prescribing Raj a low dose of a BP-low-ering drug, he was briefed about the significance of changing his harmful life-style of getting stressed easily and smoking. As he began making small but steady changes such as pursuing his hobbies, exercising and meditating regularly and establishing a friendlier rather than a controlling relationship with his daughters, he could feel a dramatic improvement in his mood and his health. He felt a lot better after giving up smoking though it was not a simple feat. Raj’s determination and Neela’s support got them out of the health crisis in a matter of six months. Raj was taken off his medication and was asked to come back for an assessment in a month’s time. He was eager to know if retirement would cause him to start wor-rying again and if his BP would go up. He was reassured that the very fact that he was concerned about it would help him to focus more on managing himself during that period. Neela, who had not had a routine health check earlier, was also advised to have her health parameters assessed.

Selva, in contrast to Raj, was so overwhelmed by his financial misfortune that he was unable to incorporate any of the suggestions made to cope better. He failed to believe that managing his personal situation in an effective manner could reverse his hypertension and failing heart function. Neither did he realize that he was risking his life by falling prey to alcohol. In short, his financial loss was blinding him from the irreparable damage he was causing to his health. He became so pessimistic that he could not even sit through a few minutes of discus-sion on how to ease the stress. He was irregular with his medications and was not keeping up with the follow-up appointments. Unfortunately, his family was not very supportive either. An attempt to have a family discussion with Selva, his wife and their son was futile. And so was the effort to get him to see a psychiatrist. He went into a vicious cycle of depression, heavy alcohol consumption and declining health and died of a massive heart attack later that year.

Reference 11. WHO Expert Consultation. Appropriate body-mass index for Asian populations and its

implications for policy and intervention strategies. Lancet 2004;363:157–63.