The Tribune - Spectrum

, April 7, 2002
Lead Article

Heart matters

Punjabis, it appears, are heading for a health catastrophe in the near future. Because of a drastic change in lifestyle from an active to a sedentary one, even young Punjabis are fast turning into patients of coronary heart disease. Whereas this disease afflicts people beyond 50 years in western countries, it is becoming extremely common amongst the young Punjabis between the age group of 30 and 45 years. In fact, by the year 2015 cardiovascular disease in Punjab will replace all other diseases as a major killer, says Aruti Nayar

FOREVER breaking fresh ground, forever reaching out to newer frontiers and working hard, revelling in and living life to the hilt with laughter, rich food and good things of life thrown in for good measure — that is the typical Punjabi view of life for you. If anything that defines the Punjabi personality and character, it is robustness of health and a capacity to live life with zest and a rare panache. Large-hearted Punjabis don't take anything to heart and their exuberance and resilience help them to sail even through the most turbulent times effortlessly, it is believed. However, it is high time that they started taking a few things seriously, if they want to save their hearts.


Recently, a study was conducted at the Tagore Heart Care and Research Centre, Jalandhar, by Dr Vijay Mahajan, Chief Cardiologist of the centre, in collaboration with Jatinder Mohan, Professor, and Meena Sehgal, Reader, Department of Psychology, Panjab University. The study was conducted on 300 individuals out of which 100 were male and 100 female patients of CHD (Coronary Heart Disease) and 100 healthy individuals who served as the control group. Research workers were appointed and the patients were asked to answer a questionnaire of 35 pages. The study followed the progress of the patients for a period of three years and tested them for the psycho-social factors that were responsible for causing CHD along with the biological and physiological causative factors. Besides this, other studies too point towards an increasing incidence of coronary heart disease in Punjab due to the nature of the diet that is replete with saturated fats such as butter and desi ghee and sugar. Coupled with an increasingly sedentary lifestyle, this life pattern spells the death-knell of robust health. Punjabis, it appears, are heading for a health catastrophe in the near future. Because of a drastic change in lifestyle from an active one to a sedentary lifestyle, even young Punjabis are fast turning into patients of CHD. Whereas this disease afflicts people beyond 50 years in western countries, it is becoming extremely common amongst the young Punjabis between the age group of 30 and 45 years, either killing them or making them handicapped in what are the most productive years of their lives. In fact, by the year 2015, cardiologists say, cardiovascular disease in Punjab will replace all other diseases as a major killer, if the present trend continues.

According to Dr Vijay Mahajan, it was found that the causative factors of CHD in Punjabis are different from those present in the West. While it is smoking, high blood pressure and increased levels of cholesterol in the blood that are the main risk or causative factors of this disease in the West, these do not play an important role amongst our population. According to the study, the causative factors that affected the Punjabis were obesity, increasing incidence of development of diabetes mellitus, increase of a type of fat known as triglycerides, and low amounts of "good" cholesterol called HDL in the blood. All these abnormalities are collectively known as Syndrome-X. The lack of physical exercise, excessive use of alcohol and a diet which is rich in saturated fats and refined sugar play an important role in creating Syndrome-X. So all those who love to gorge on the desi ghee-laden sarson ka saag and gajar ka halwa stuffed with khoya and dry fruits and luxuriate while sipping their Patiala pegs as they dig in to butter chicken and malai koftas, would better stand forewarned.

Another matter of grave concern is the higher incidence of CHD in rural Punjabis, especially amongst the younger generation. The world over, the rural population is less prone to CHD as compared to the urban population. However that does not seem to be the case as far as Punjabi youth are concerned because there is almost an equal incidence of CHD amongst rural as well as urban population. This is because even in rural areas traditionally large amounts of saturated fats are consumed and there is hardly any physical exercise.

The easy availability of migrant labour from UP, Bihar and Orissa ensures that even in the rural areas very little physical labour is done by the farmers. As Subrata Das, Medical Superintendent of Fortis Heart Institute puts it: We have inherited a dietary system. Even the average glass of lassi is bigger in Punjab than it is elsewhere. Because the youngsters no longer want to work hard in the fields, the food that they eat is now eating them because they are not working as much as their forefathers were. While the dietary pattern remains unchanged, the lifestyle has changed drastically."

Dr Achintya Moulick, Senior Consultant, Cardiothoracic Surgery in Fortis, too is of the opinion that North Indians and Punjabis more so have a genetic tendency to have higher lipid levels or familial hyperlypodaemia. He feels a lot of demographic studies are required to focus on the problem and generate awareness of the disease. Also a contributory factor is the attitude that Indians have towards health care, feels Dr Moulick. "We have this attitude of relying on government hospitals and free treatment. No money is spent on health care. We are impractical and think of how God is going to cure us and take care of all our problems. We never think that how we ourselves can take care of our bodies. We leave too much to fate and by the time we realise life is finite and the body a machine, it is often too late. In this country one has to work hard even to remain where one is."

The mechanisation of agriculture and the common use of tractors, combines and harvesters have brought in a relatively comfortable situation for farmers, making life more sedentary. Even the mandatory walk to the well is no longer the practice in most villages, Dr Mahajan says, adding that even for that the farmer uses the motor cycle or scooter. Cars, jeeps and two-wheelers are commonly used means of transport even in the villages. Gone are the days of either walking on foot or cycling.

In addition, use of alcohol is increasing amongst the younger generation, making them more prone to CHD.

Explaining the psycho-social factors found responsible for increasing incidence of CHD, Meena Sehgal explains how when we talk of diseases, it is either the health orientation or illness orientation of the personality that plays a role in determining how an individual manages his/her stress. Both the parameters,etiological as well as psychological, could explain 70 per cent of the risk factors. One was aware that the typical ‘A type’ personality — high on ambition, need for achievement and intense job-involvement characterised by speed and impatience as behavioural traits — was more prone to heart disease. But all these factors were clubbed together and one did not know which were the causative factors. According to the study, the AHA Syndrome — aggression, hostility and anger — causes CHD. It is not just anger by itself, but how you express anger. "Anger out" types or people who indulge in outward expression of anger are not as much at risk as are the "Anger in" types who internalise anger. This is because outward expression of anger to an optimum extent acts as a release valve. "Anger in" can be damaging.

Stress of major life events such as death, divorce, financial reversal and major illness can be managed as one recovers from them, after the initial setback. It is chronic stress or daily hassles that affect an individual more and one has to watch out for the effects of these. Since one is required to cope with them every day, these have a deeper effect. In the daily hassles are included problems with the spouse, mother-in-law or daughter-in-law problems or a negative working environment. Anger management, feels Meena Sehgal, can result in definite reduction of medical costs. Since these are sizable, modifiable factors, they can benefit from intervention at an early stage. Families of cardiac patients should be tested for the psychological risk factors since in their case heredity factors are combined with the environmental ones.

The study also busted the notion that women are not prone to CHD. Women were found to be equally vulnerable. In fact, the negative factors were present more in women since they were higher on chronic stress and daily hassles. The significant factor is that being an "ideal woman" required being patient and submissive. The fact that overt expression of anger was not as socially acceptable in case of women as it was in case of men is taking its toll as far as the health of women is concerned.

The study found that ill people were lower on the protective factors — optimism and social support. It is these protective factors that give will power and desire to live. Meena Sehgal maintains that you can improve your health significantly by checking risk factors and getting "toxic" components identified. Prevention is much better because if you are tested for psychological risk factors that might make you a sick person and undertake behaviour modification therapy it can help you to manage the risk factors. Dr Moullick is of the view that 30 to 40 per cent of the patients have some psychological problem as well.

According to Harbans S. Wasir, Chief Cardiologist and Medical Adviser, Batra Hospital, in 1990, heart disease accounted for 25.5 per cent of all-cause mortality, while in 1998 it rose to 30.2 per cent. The prevalence of CHD in urban adults was 3.5 per cent in 1960, and it increased to 9.5 per cent in 1990s. In the 60s, 2 per cent of the rural population was afflicted by the disease, whereas in the 90s the figure rose to 4 per cent. Therefore, one can state that there has been an increase in mortality as well as prevalence. Also there has been an increase in the incidence of people both in the urban and rural areas coming for treatment of heart disease.

The world over cigarette smoking, hypertension and high blood lipids are the major risk factors for CHD. The minor ones are sedentary habits, suppressed anger and a hostile environment. I found that half of my patients had never smoked, their cholesterol level was normal. That is where lack of social support, problems with the spouse and a hostile environment serve as causative factors. Higher the scores of anger out, less the chances of getting hypertension. Studies in the young patients showed higher levels of triglycerides. When one correlated these with angiographic details, one found high LDL, a major metabolic risk factor.

Everyone is talking of risk factors. I would like to talk of "coronary protective factors".

Role of physical exercise and diet

It helps keep the weight normal, blood sugar, lipids and blood cholesterol levels are also brought down. The adoption of physical exercise is the only way to increase HDL (friendly cholesterol). It increases levels of nitric oxide in the body, which has been found to be a protective factor for the endothelium or the inner lining of the blood vessels.

Dr Wasir feels regular exercise is also the best agent to achieve mental exercise. It releases endorphins — ask people who do exercise as to how good they feel. Those who do not, only realise it after they start.

Mental relaxation is also an important protective factor. Yogic kriyas, a periodic attending of satsangs and participation in religious congregations, group or community activity where people can get together and share are also beneficial. What is needed is that people should laugh "with" each other not "at" each other, what is increasingly being done in the competitive world of today.

Role of diet

One must consume as many calories as do not make one put on weight. If one is not gaining weight, it means one’s diet is fine.

Those who wish to protect their hearts and its roots (coronary arteries) and the contents therein, must avoid all that causes affliction of the mind.

— Charaka Samhita

In comparison to people from the other states, Punjabis are more vulnerable to heart attacks due to the fat content in their diet. A heavy meal adversely affects the heart because food releases many hormones in the bloodstream that increase the heart beat and blood pressure. A temporary rise in the blood pressure increases the oxygen requirements and puts extra pressure on the heart.

It is important to treat the findings of such studies as a wake-up call and take appropriate remedial measures. The process of disease begins during childhood itself so even though you cannot change your parents, you can change your lifestyle. In the West awareness coupled with action to counter the risk factors led to a decrease in the incidence of CHD by almost 50 per cent. Now it is the adoption of a western lifestyle that seems to be creating health hazards as far as we Indians are concerned. What we need to do is to consciously introduce lifestyle changes.

These changes can start with keeping a watch on the food that children eat and ensure they get their quota of greens and fruits and do not eat only junk food. Eating rich calorie-laden foods as in too many chocolates, chips, burgers as a treat or reward lays the foundation of faulty eating habits. Parents and schools can emphasise the significance of physical exercise and discourage sedentary habits. Prolonged TV watching can lead to sluggishness and prevent children from enjoying the outdoors and burning calories, besides reinforcing a sedentary pattern of living.

The World Health Day today will be an appropriate day to resolve to actively think about and act on issues that directly affect our health.

Heart facts

  • Syndrome X makes Indians four times more susceptible to heart attacks than Europeans, Americans, Japanese and Chinese. Indians below the age of forty are at ten times higher a risk than the others. According to WHO, by 2010 India will have 60 per cent of the world's heart patients and the year 2015, CHD will emerge as the biggest killer in Punjab.

  • An in-house survey done by the Department of Cardiology at Sir Ganga Ram Hospital, New Delhi, found that 10 to 15 per cent of the patients undergoing bypass surgery were in the age group of 35-45 years.

  • Due to stress a lot of chemicals like adrenaline and histamines are released in the body, which have a detrimental effect on the body. These chemicals constrict the coronary arteries and reduce the blood supply to the heart. They also stimulate us into overeating, resulting in excessive consumption of calories. The result of getting addicted to junk-food, smoking and drinking is that more of the younger population is turning up for surgeries and cardiac interventions, which means that they are at the risk of getting the procedure repeated in their older age.

According to Prof. S. L. Sharma, Course Director, Institute of Correctional Administration, a Punjabi has an achievement-oriented personality that compels him to set new goals, strive for betterment and break new frontiers. After Gujaratis, Punjabis were the second community to migrate abroad. There is a linkage between the achievement motivation of a community and the incidence of heart problems.

Prof. Sagar Sharma, Professor Emeritus, Department of Psychology, Panjab University, is of the view that stress is simply a mismatch between the person and the environment. The demands of the environment are changing and even those with fewer abilities have more needs. Vital psychological signs— anger, anxiety and depression — are the reactions to stress. It has been repeatedly documented in the studies that it's neither an outward nor an inward expression of anger that is damaging, but the frequency and intensity with which anger is experienced. A sense of perceived unfairness and injustice and imposition of unrealistic expectations on self (I must…) and on others (They should…) cause anxiety and anger. Currently there is a lot of emphasis on intervention strategies that help to cultivate positive emotions that are suited for preventing and treating problems that are rooted in negative emotions.

Relationship between hostility and the heart

YOUNG women and men who rate high in aggression, anger and other forms of hostility are more likely to develop hardening of arteries at an early age, according to a report in The Journal of the American Medical Association. "Even when you are young, the more hostile you are, the greater your chances of developing coronary artery calcification, the beginning stage of heart disease," said Dr Carlos Iribarren, who led the research team comparing heart disease and hostility.

The study included 374 women and men who were 18 to 30 years old at the beginning of the programme in 1985. They took a well-established psychological test to measure hostility. Five years and 10 years after the first tests, they again completed the Cook-Medley hostility test of 50 true-false questions.

Scientists then used electron-beam tomography to measure heart artery calcification, or hardening. They compared those measurements with the results of the hostility tests, said Iribarren, who works for the Kaiser Permanente Medical Care Program in Oakland, California.

"The researchers found that those subjects who had hostility scores above the median had about 2.5 times the risk of having any coronary artery calcification than those with scores below the median," said a source in The Journal of the American Medical Association.

The study adjusted for factors like smoking, diet and exercise, which can also contribute to the hardening of the arteries. Doctors said they hope the research will inspire young people who exhibit constant hostility to learn how to manage their anger and reduce their risk of heart attack later in life. But they advised that more research is necessary.

Clinical trials are needed to test whether reduction in hostile attitudes and behaviour is an effective means of preventing artherosclerosis and thus ameliorating the burden of coronary disease," Iribarren said.

The article described hostility as a personality and character trait with these components: Anger, cynicism and mistrust of others, aggressive behaviour, both overt and repressed. Other studies on the same subject have also shown a link between high hostility levels and coronary artery hardening, high blood pressure and earlier death rates.

Several theories have been put forward to explain why hostility may increase cardiovascular risk. For instance, unhealthy behaviours like smoking and alcohol use are often associated with hostility. However, the scientists cautioned that chemical and hormonal effects from hostility might also be involved.

Stress hormones cause the blood pressure to go up and increase the tendency of platelets (the blood cells which are responsible for blood-clotting) to stick together. These changes in the body may then be responsible for the hardening of the arteries, including calcium deposits.