Being Indian A setup for a Heart Attack !

Ravi Jandhyala, MD, FACC
Director Interventional Cardiology
Kaiser Permanente, ...
500

No. of deaths
(left axis)

400
300

Male
Female

% of all deaths
(right axis)

200
100
0

35
30
25
20
15
10
5
0

Hear...
In the past three decades, heart disease rates have:

doubled in rural areas of India, and
tripled in its urban areas.
A major study found that the prevalence of heart disease
in New Delhi and Chennai, was 10% and 11% respectively—
slightly ...
♥ Coronary heart disease among Indians strikes early, strikes
hard, and strikes unexpectedly.
♥ Heart disease among young ...
♥

Approximately one-third of all first heart attacks among
Indians occur in Indians younger than 45, and their heart
dise...
♥ Heart disease rates continue to increase on the Indian
subcontinent and are now as high there as in Indians living in
ot...
By 2020, according to the WHO the number of Indian citizens
dying each year from heart disease will exceed 2.4 million,
mo...
Animation of how a blockage develops and causes a heart attack
• What causes the blockage to build up ?
•
•
•
•
•
•

High levels of Bad Cholesterol
High Blood Sugar
Smoking
High Blood P...
Cigarette smoking is the leading preventable cause of
mortality, responsible for nearly six million deaths worldwide
and o...
Metabolic Syndrome
Metabolic Syndrome ( Syndrome X )
• Waist Size
– > 36 inches (90 cms) (Men)
– > 32 inches (80 cms) (Women)
Plus any two of...
Unmet clinical need associated with
abdominal obesity
CV risk factors in a typical patient with abdominal obesity

Patient...
Abdominal obesity has reached
epidemic proportions worldwide
Men (%)
USa
Spainb
Italyc
UKd
Francee
Netherlandsf
Germanyg

...
Growing prevalence of abdominal
obesity
US National Health and
Nutrition Examination Survey (NHANES)
NHANES III

NHANES

(...
Abdominal obesity increases the risk
of developing type 2 diabetes
24

Relative risk

20
16
12
8
4
0
<71

71–75.9

76–81

...
Metabolic syndrome has a negative
impact on CV health and mortality
No metabolic syndrome
Metabolic syndrome

25

25

*
20...
Tape Measure as Important as the Stethoscope
What to do ?
• Stop Smoking
• Keep active 30 to 80 minutes of moderate
intensive activity 3 to 4 times a week
• Eat a bala...
• Sleep
• Stress
Why see a Doctor?
The risk factors have no symptoms
High Blood Pressure
High Blood Sugar –Diabetes
High Cholesterol and Tr...
Diabetes
• One in 7 CA residents has Diabetes
• A 32% increase in last decade
• Costs tax-payers and businesses $ 24 billi...
High Blood Pressure
By decreasing daily salt intake to 3

gms a day:

A reduction in the number of new cases of coronary heart disease by up t...
Cigarette smoking is the leading preventable cause of
mortality, responsible for nearly six million deaths worldwide
and o...
Exercise
• Energy consumption: Metabolic equivalent
MET- 3.5ml O2/kg/min

– Sleeping 1 MET/hr
– Desk work 1.5 MET/hr
– Wal...
Exercise
How much?
How frequent ?
Points to take home:
Even 15 minutes a day of walking briskly, reduced Coronary Heart
Disease (CHD) significantly.
Exercis...
Lack of exercise:
contributing to diseases such as diabetes and cancer, is
now causing as many deaths as smoking across th...
Exercise
• Each ONE MET increase in exercise capacity
confers 12% reduction in Major adverse
cardiovascular outcomes ( Dea...
Walking pace and associated
relative risk of cardiovascular
disease
Walking pace

Relative risk

Normal (2-2.9 mph)

0.82
...
We wonder how to quantify the benefits of exercise. This study
looked at 26 published studies since 1995.
Points to take home:
Even 15 minutes a day of walking briskly reduced Coronary Heart
Disease (CHD) significantly. More is ...
A lack of exercise, contributing to diseases such as
diabetes and cancer, is now causing as many deaths as
smoking across ...
1940’s

Non Violent Movement
50 years later

Non Movement Violence on the body
Diet
• Balanced Diet:

– Carbohydrates 55%
– Fats 30%
– Proteins 15%
A study of 44,500 people in England and
Scotland showed vegetarians were 32% less
likely to die or need hospital treatment...
Good
• Complex carbohydrates : Whole grains,
legumes, vegetables.
• Fiber: 25 grams a day.
• Fats: Monounsaturated fats li...
Not so good
• Added and refined sugars: Soft drinks,
sweetened fruit drinks, sweet desserts
• Salt
• Saturated fats: Red m...
* Healthy life style is for 'all' not just the over weight.

* Healthy living should be 'Excuse-Proof'.

* Choose 'eleganc...
*

Add support.
Enlist a friend, family member or a cyber buddy as your
partner.

*

Know that it's OK to make mistakes.

...
Calories don’t lie !
We can no longer eat

rich food like a poor man !
We should all:
Eat less
Eat out less
and
Move more.
“Lack of activity destroys the good condition of
every human being, while movement and
methodical physical exercise save i...
“Take care of your body. It’s the only
place you have to live.” – Jim Rohn

“To insure good health: eat lightly, breathe d...
AyurAveda
•Eat right
•Exercise right
•Don’t take yourself too
seriously!
Lifetime risk (to age 95) for CVD and
mortality at age 50
Risk factor level

Men:
Lifetime
CVD risk
(%)

Women:
Lifetime
C...
• 23 ½ hours by Dr. Mike Evans on YouTube
• ravijandhyala@gmail.com
• Though we have several times increased risk.
• We can prevent death and heart attacks!
• Yes !!!

• Thank You.
HRR Healthy Life Style Dr Ravi Jandhyala heart health
HRR Healthy Life Style Dr Ravi Jandhyala heart health
HRR Healthy Life Style Dr Ravi Jandhyala heart health
HRR Healthy Life Style Dr Ravi Jandhyala heart health
HRR Healthy Life Style Dr Ravi Jandhyala heart health
HRR Healthy Life Style Dr Ravi Jandhyala heart health
HRR Healthy Life Style Dr Ravi Jandhyala heart health
HRR Healthy Life Style Dr Ravi Jandhyala heart health
HRR Healthy Life Style Dr Ravi Jandhyala heart health
HRR Healthy Life Style Dr Ravi Jandhyala heart health
HRR Healthy Life Style Dr Ravi Jandhyala heart health
HRR Healthy Life Style Dr Ravi Jandhyala heart health
HRR Healthy Life Style Dr Ravi Jandhyala heart health
HRR Healthy Life Style Dr Ravi Jandhyala heart health
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Dr Ravi Jandhyala PPT on Heart health

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  • Despite therapeutic advances, cardiovascular disease remains the leading cause of death (USA)
    Survey data from the Centers for Disease Control National Center for Health Statistics in the USA illustrate the continuing burden of mortality arising from cardiovascular disease.
    The left hand axis shows the numbers of deaths attributed to specific conditions in men and women in 2002. The right hand axis expresses the number of deaths in men and women combined as a percentage of the total numbers of deaths during that year.
    Cardiovascular disease remains the leading killer, with more impact on mortality rates than other major sources of mortality, such as cancer, respiratory disease, accidents, or diabetes.
    National Center for Health Statistics. Health, United States, 2004 With Chartbook on Trends in the Health of Americans. Hyattsville, Maryland: 2004.
  • Unmet clinical need associated with abdominal obesity
    Abdominal obesity (measured by high waist circumference) represents a major health threat, as it often presents in association with a cluster of cardiometabolic risk factors.
    Indeed, 86% of abdominally obese subjects have one or more cardiovascular risk factors, and 24% have at least two additional cardiovascular risk factors that identify them as having the metabolic syndrome.1
    Clearly, abdominal obesity signifies a marked increase in overall cardiovascular risk that is often driven by the progression of multiple risk factors.
    New approaches to the management of cardiovascular risk that address this complex pathophysiology are needed.
    1. NHANES 1999–2000. http://www.cdc.gov/nchs/nhanes. Data downloaded September 2004 using SAS software (Data on file)
  • Abdominal obesity has reached epidemic proportions worldwide
    Surveys in various countries suggest a high prevalence of abdominal obesity, using criteria similar to those used for the metabolic syndrome by NCEP/ATP III. Further details of the populations in each country are given below:
    CountryYearAge range studied
    US1999–2000 20
    France2003 15
    Spain 1997–818-74
    Italy 1998 35-74
    Netherlands1993-97 20-59
    UK2000–1 19-64
    Germany 1994–525–74
    Alvarez Leon EE, Ribas Barba L, Serra Majem L. Prevalence of the metabolic syndrome in the population of Canary Islands, Spain. Med Clin (Barc) 2003;120:172-4.
    Charles MA, Basdevant A, Eschwege E. Prevalence of obesity in adults in France: the situation in 2000 established from the OBEPI Study. Ann Endocrinol (Paris) 2002;63:154-8.
    Osservatorio Epidemiologico Cardiovascolare Italiano. Ital Heart J 2004,5(suppl.3):49-92.
    Visscher TLS, Seidell JC. Time trends (1993-1997) and seasonal variation in body mass index and waist circumference in the Netherlands. Int J Obes 2004;28:1309-16.
    Ruston D, Hoare J, Henderson L, Gregory J. The National Diet &amp; Nutrition Survey: adults aged 19 to 64 years. Office of National Statistics (UK), 2004, National Diet and Nutrition Survey, vol. 4.
    Ford ES, Mokdad AH, Giles WH. Trends in waist circumference among U.S. adults. Obes Res 2003;11:1223-31.
    Liese AD, Döring A, Hense HW, Keil U. Five year changes in waist circumference, body mass index and obesity in Augsburg, Germany. Eur J Nutr 2001;40: 282-8.
  • Growing prevalence of abdominal obesity
    The National Health and Nutrition Examination Survey is an ongoing observational study. The analyses shown in this slide have included 6346 men and women for the 1988-1994 cohort and 1677 men and women for the 1999–2000 cohort.
    The data shows clearly that the prevalence of abdominal obesity increased markedly in the USA between these two time points.
    Ford ES, Mokdad AH, Giles WH. Trends in waist circumference among U.S. adults. Obes Res 2003;11:1223-31.
  • Abdominal obesity increases the risk of developing type 2 diabetes
    These data are from the Nurses’ Health Study,1 an observational study that followed a cohort of 43,581 women between 1986 and 1994 in the USA. The analysis presented here was designed to define the association between waist circumference and the risk of developing type 2 diabetes.
    The risk of developing type 2 diabetes increased linearly with an increasing waist circumference. The relative risk for women at the 90th percentile of waist circumference (equivalent to a waist measurement of 92 cm [36 in]) was 5.1 (95% CI 2.9-8.9) compared with women at the 10th percentile (waist measurement of 67 cm [26.2 in]). High waist circumference is a powerful predictor of an increased risk of developing type 2 diabetes.
    Previous slides have defined the central role of abdominal obesity in the diagnostic criteria for the metabolic syndrome. People with the metabolic syndrome have a 5-fold greater risk of developing type 2 diabetes, if not already present.2
    1. Carey VJ, Walters EE, Colditz GA et al. Body fat distribution and risk of non-insulin-dependent diabetes mellitus in women. The Nurses&apos; Health Study. Am J Epidemiol 1997;145:614-9.
    2. Stern MP, Williams K, Gonzalez-Villalpando C, Hunt KJ, Haffner SM. Does the metabolic syndrome improve identification of individuals at risk of type 2 diabetes and/or cardiovascular disease? Diabetes Care 2004;27:2676-81.
  • Metabolic syndrome has a negative impact on CV health and mortality
    Although it has been widely assumed that the metabolic syndrome is associated with an increased risk of cardiovascular disease, relatively little research has been done on the prevalence of cardiovascular morbidity and mortality in patients with the syndrome.
    Isomaa and colleagues assessed cardiovascular morbidity and mortality in a cohort of subjects (N=3606; age, 35 to 70 years) participating in a longitudinal study in Finland and Sweden (the Botnia study). Median follow-up was 6.9 years.
    Subjects meeting the definition of metabolic syndrome were significantly more likely to have a history of CHD, myocardial infarction, and stroke than those without the syndrome. The presence of metabolic syndrome was associated with significantly increased risk of CHD (RR, 2.96, p&lt;0.001), myocardial infarction (RR 2.63, P&lt;0.001), and stroke (RR 2.27, p&lt;0.001).
    Overall, individuals with the metabolic syndrome were therefore 2–3-fold more likely to die from an adverse cardiovascular event than individuals without the metabolic syndrome.
    People with the metabolic syndrome are at increased risk of being twice as likely to die from and tree times as likely to have a heart attack or stroke compared to people without metabolic syndrome.
    Isomaa B, Almaren P, Tuomi T, et al. Cardiovascular morbidity and mortality associated with the metabolic syndrome. Diabetes Care 2001;24:683-689.
  • HRR Healthy Life Style Dr Ravi Jandhyala heart health

    1. 1. Being Indian A setup for a Heart Attack ! Ravi Jandhyala, MD, FACC Director Interventional Cardiology Kaiser Permanente, Orange County, CA
    2. 2. 500 No. of deaths (left axis) 400 300 Male Female % of all deaths (right axis) 200 100 0 35 30 25 20 15 10 5 0 Heart disease and stroke Cancer Accidents Data for 2002 National Center for Health Statistics 2004 Chronic lower resp. disease Diabetes % All deaths (male + female) Number of deaths (thousands) Despite therapeutic advances, cardiovascular disease remains the leading cause of death (USA)
    3. 3. In the past three decades, heart disease rates have: doubled in rural areas of India, and tripled in its urban areas.
    4. 4. A major study found that the prevalence of heart disease in New Delhi and Chennai, was 10% and 11% respectively— slightly higher than the 10% rate among the Indian participants in the American based CADI Study
    5. 5. ♥ Coronary heart disease among Indians strikes early, strikes hard, and strikes unexpectedly. ♥ Heart disease among young Indians (young defined as under 45) is often severe and diffuse, and it follows a malignant course that may be classified as Type I heart disease. ♥ Indians typically develop a heart attack 10 years earlier than other populations. ♥ Young Indians have a much higher risk of heart attack than similarly aged people in other populations.
    6. 6. ♥ Approximately one-third of all first heart attacks among Indians occur in Indians younger than 45, and their heart disease is often comparable in severity to that of older Indians. ♥ Serious forms of coronary artery disease, especially left main coronary artery disease and three- vessel disease are twice as common among Indians as in whites, and even more common among Indian women. ♥ Diabetes only partially explains the prematurity and severity of Indian heart disease. In addition to traditional risk factors such as diabetes. Indians have high levels of newly discovered "emerging" risk factors such as homocysteine, CRP and LP(a). Together, these constitute the most likely cause of the prematurity and severity of heart disease among Indians.
    7. 7. ♥ Heart disease rates continue to increase on the Indian subcontinent and are now as high there as in Indians living in other parts of the world. ♥ The rates are as high in Pakistan, Bangladesh, and Sri Lanka as they are in India. ♥ A 2005 study found that one in four Pakistani adults above age 40 has heart disease. ♥ Although heart disease rates were virtually identical in India and the US 30 years ago, they are currently four times higher in India. ♥ This marked difference is due to a more than 50% decrease in heart disease in the US and a more than 200% increase in India.
    8. 8. By 2020, according to the WHO the number of Indian citizens dying each year from heart disease will exceed 2.4 million, more than twice the number in 1990. One of every four cardiac patients in the world will be Indian.
    9. 9. Animation of how a blockage develops and causes a heart attack
    10. 10. • What causes the blockage to build up ? • • • • • • High levels of Bad Cholesterol High Blood Sugar Smoking High Blood Pressure High Body Weight especially Waist size Inactivity
    11. 11. Cigarette smoking is the leading preventable cause of mortality, responsible for nearly six million deaths worldwide and over 400,000 deaths in the United States annually. If current trends continue, tobacco will kill more than eight million people worldwide each year by the year 2030.
    12. 12. Metabolic Syndrome
    13. 13. Metabolic Syndrome ( Syndrome X ) • Waist Size – > 36 inches (90 cms) (Men) – > 32 inches (80 cms) (Women) Plus any two of the following: • Sugar – > 100mgs/dl • Cholesterol HDL – < 40mg/dl (men) – < 50 mg/dl (women) • Triglycerides – > 150mg/dl • Blood Pressure • Systolic >130 mm Hg • Diastolic > 85 mm Hg
    14. 14. Unmet clinical need associated with abdominal obesity CV risk factors in a typical patient with abdominal obesity Patients with abdominal obesity (high waist circumference) often present with one or more additional CV risk factors
    15. 15. Abdominal obesity has reached epidemic proportions worldwide Men (%) USa Spainb Italyc UKd Francee Netherlandsf Germanyg Women (%) Total (%) 36.9 30.5 24.0 29.0 – 14.8 20.0 55.1 37.8 37.0 26.0 – 21.1 20.5 46.0 34.7 31.5 27.5 26.3 18.2 20.3 High waist circumference: >102 cm (>40 in) in men or >88 cm (>35 in) in women except in Germany (>103 cm [41 in] and >92 cm [36 in], respectively) Ford et al 2003; bAlvarez-Leon et al 2003; cOECI 2004; dRuston et al 2004; eObepi 2003; fVisscher & Seidell 2004; gLiese et al 2001 a
    16. 16. Growing prevalence of abdominal obesity US National Health and Nutrition Examination Survey (NHANES) NHANES III NHANES (1988–1994) (1999–2000) Relative change Men 29.5% 36.9% + 28% Women 46.7% 55.1% + 18% Abdominal obesity defined as waist circumference: >102 cm (>40 in) in men or >88 cm (>35 in) in women Ford et al 2003
    17. 17. Abdominal obesity increases the risk of developing type 2 diabetes 24 Relative risk 20 16 12 8 4 0 <71 71–75.9 76–81 81.1–86 86.1–91 91.1–96.3 Waist circumference (cm) Carey et al 1997 >96.3
    18. 18. Metabolic syndrome has a negative impact on CV health and mortality No metabolic syndrome Metabolic syndrome 25 25 * 20 *p<0.001 15 10 * * 5 Mortality rate (%) Prevalence (%) 20 CHD MI Isomaa et al 2001 Stroke * 15 * 10 5 0 0 *p<0.001 All-cause Cardiovascular mortality mortality
    19. 19. Tape Measure as Important as the Stethoscope
    20. 20. What to do ? • Stop Smoking • Keep active 30 to 80 minutes of moderate intensive activity 3 to 4 times a week • Eat a balanced diet • Weight management especially waist size • See a Doctor
    21. 21. • Sleep • Stress
    22. 22. Why see a Doctor? The risk factors have no symptoms High Blood Pressure High Blood Sugar –Diabetes High Cholesterol and Triglycerides Do not have any symptoms.
    23. 23. Diabetes • One in 7 CA residents has Diabetes • A 32% increase in last decade • Costs tax-payers and businesses $ 24 billion annually
    24. 24. High Blood Pressure
    25. 25. By decreasing daily salt intake to 3 gms a day: A reduction in the number of new cases of coronary heart disease by up to 120,000; stroke by up to 66,000 and myocardial infarctions by up to 99,000 annually. A reduction in the number of deaths from any cause by up to 92,000 annually. A savings in health care costs of up to 24 billion annually. The projected cardiovascular benefits are similar to those of populationwide reductions in smoking, obesity and cholesterol levels.
    26. 26. Cigarette smoking is the leading preventable cause of mortality, responsible for nearly six million deaths worldwide and over 400,000 deaths in the United States annually. If current trends continue, tobacco will kill more than eight million people worldwide each year by the year 2030.
    27. 27. Exercise • Energy consumption: Metabolic equivalent MET- 3.5ml O2/kg/min – Sleeping 1 MET/hr – Desk work 1.5 MET/hr – Walking 2mph 2 METS – Tennis Singles 5 METS
    28. 28. Exercise How much? How frequent ?
    29. 29. Points to take home: Even 15 minutes a day of walking briskly, reduced Coronary Heart Disease (CHD) significantly. Exercise of 150 minutes of moderate intensity per week ( minimum recommended by US Federal Guidelines ) reduced CHD by 14%. For those who achieved 300 minutes per week reduced CHD by 20% compared to sedentary. And for those who exercised 750 minutes of moderate intensity of exercise reduced their risk by 25%.
    30. 30. Lack of exercise: contributing to diseases such as diabetes and cancer, is now causing as many deaths as smoking across the world. Published in Lancet
    31. 31. Exercise • Each ONE MET increase in exercise capacity confers 12% reduction in Major adverse cardiovascular outcomes ( Death, Stroke, Heart attack) • Increase in 4 METS confers almost 50% reduction in Major adverse cardiovascular events
    32. 32. Walking pace and associated relative risk of cardiovascular disease Walking pace Relative risk Normal (2-2.9 mph) 0.82 Brisk (3-3.9 mph) Very brisk ( > 4 mph) 0.58 0.17 p for the trend, <0.001, compared with "easy pace" of <2 mph Tanasescu M et al. Circulation. 2003. Available at: http://circ.ahajournals.org.
    33. 33. We wonder how to quantify the benefits of exercise. This study looked at 26 published studies since 1995.
    34. 34. Points to take home: Even 15 minutes a day of walking briskly reduced Coronary Heart Disease (CHD) significantly. More is better. Keep moving. Exercise of 150 minutes of moderate intensity per week ( minimum recommended by US Federal Guidelines ) reduced CHD by 14%. For those who achieved 300 minutes per week reduced CHD by 20% compared to sedentary. And for those who exercised 750 minutes of moderate intensity of exercise reduced their risk by 25%.
    35. 35. A lack of exercise, contributing to diseases such as diabetes and cancer, is now causing as many deaths as smoking across the world, a study suggests. Published in Lancet
    36. 36. 1940’s Non Violent Movement 50 years later Non Movement Violence on the body
    37. 37. Diet • Balanced Diet: – Carbohydrates 55% – Fats 30% – Proteins 15%
    38. 38. A study of 44,500 people in England and Scotland showed vegetarians were 32% less likely to die or need hospital treatment as a result of heart disease.
    39. 39. Good • Complex carbohydrates : Whole grains, legumes, vegetables. • Fiber: 25 grams a day. • Fats: Monounsaturated fats like Canola, Olive, Safflower oils, many nuts like almonds cashews, pecans. • Omega-3 Fatty acids: Fatty fish including Salmon, Tuna. Lesser amounts in canola oil, tofu, flaxseed and dark green leafy vegetables.
    40. 40. Not so good • Added and refined sugars: Soft drinks, sweetened fruit drinks, sweet desserts • Salt • Saturated fats: Red meat, whole milk, butter cheese • Hydrogenated fats: a mixture of saturated and trans fats- fried foods • Trans fats: deep fried foods, processed foods, crackers, cookies
    41. 41. * Healthy life style is for 'all' not just the over weight. * Healthy living should be 'Excuse-Proof'. * Choose 'elegance' over force. Dietary battles are not won when you work hard, but when you work smart. * Make your eating plan 'automatic'. * Know your body. * Stay satisfied, Stay Positive. To lose weight, you need to eat.
    42. 42. * Add support. Enlist a friend, family member or a cyber buddy as your partner. * Know that it's OK to make mistakes. * You move, you lose. * Make a gesture. Buy walking shoes or pedometer or club membership or throw away the unhealthy foods from the pantry. * The do it.
    43. 43. Calories don’t lie !
    44. 44. We can no longer eat rich food like a poor man !
    45. 45. We should all: Eat less Eat out less and Move more.
    46. 46. “Lack of activity destroys the good condition of every human being, while movement and methodical physical exercise save it and preserve it.” – Plato
    47. 47. “Take care of your body. It’s the only place you have to live.” – Jim Rohn “To insure good health: eat lightly, breathe deeply, live moderately, cultivate cheerfulness, and maintain an interest in life.” – William Londen
    48. 48. AyurAveda •Eat right •Exercise right •Don’t take yourself too seriously!
    49. 49. Lifetime risk (to age 95) for CVD and mortality at age 50 Risk factor level Men: Lifetime CVD risk (%) Women: Lifetime CVD risk (%) Men: Median survival (y) Women: Median survival (y) Optimal risk factors* 5.2 8.2 >39 >39 >1 not-optimal risk factor 36.4 26.9 36 39 >1 elevated risk factor 45.5 39.1 35 39 1 major risk factor 50.4 38.8 30 35 >2 major risk levels=total cholesterol <180 mg/dL (4.65 mmol/L), 68.9 50.2 28 31 *Optimal risk factor blood pressure <120/80 mm Hg, nonsmoker, and nondiabetic factors Lloyd-Jones DM et al. Circulation 2006; available at: http://circ.ahajournals.org.
    50. 50. • 23 ½ hours by Dr. Mike Evans on YouTube • ravijandhyala@gmail.com
    51. 51. • Though we have several times increased risk. • We can prevent death and heart attacks! • Yes !!! • Thank You.

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