Today, in India, we have more than 40 million pts with diabetes. And that is why India has been designated as capital of diabetes.
Atherosclerosis begins early in life. Inflammatory cells attract modified lipoproteins to the vessel wall, leading to a thickened, fatty intima. Eventually the lesion develops until a fibrous cap covers an atheromatous lipid-laden gruel. Inflammation can weaken the cap, leading to high risk of rupture and subsequent thrombosis as the lipid core interacts with coagulation factors in the blood. In later stages, the cap becomes thicker, more fibrous, and sometimes calcified. The risk of rupture is reduced (although thrombus may still occur through superficial erosion), but stenosis can be severe, causing ischemic symptoms such as angina and intermittent claudication. Libby P. Current concepts of the pathogenesis of the acute coronary syndromes. Circulation . 2001;104:365-372.
Cholesterol is a soft waxy substance found among the lipids in the bloodstream and in all of your body’s cells. 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 as well as other major organs. We get cholesterol from two ways. Our bodies make it and the rest comes from animal products we eat. It is frequently measured to promote health and prevent disease. Desirable levels of total cholesterol levels should be at 200 or less. 240 is considered high but it will depend on the HDL and LDL levels if at this level there is a risk to your health. It is a major component of the plaque that clogs arteries. Cholesterol and other fats can’t dissolve in the blood. They have to be transported to and from cells by special carriers called lipoproteins.
HDL or high density lipoprotein is know as the good cholesterol, it helps to bind to some of the bad cholesterol and carry it out of the body. It does not have the tendency to clog arteries. The target level is greater than 35mg/dl. High levels of >60 can actually negate one other risk factor. Studies suggest that high levels of HDL cholesterol reduce your risk of a heart attack.
The Facts About Fat – Certain fats are essential for good nutrition and health. Fats provided essential fatty acids which the body can’t manufacture, they act as insulators to maintain body temperature and they improve the palatability of food and promote digestion. Knowing which fats raise LDL cholesterol and which ones don’t is very important. Saturated fat, trans fatty acids, and dietary cholesterol raise blood cholesterol. Some studies suggest that using monounsaturated and polyunsaturated may lower cholesterol levels slightly.
Saturated fats can cause an increase in cholesterol. What is saturated fat? It is fat that is saturated with hydrogen and is a solid at room temperature. Examples are lard and butter. Saturated fats increase levels of LDL, decrease levels of HDL and increases total cholesterol. The American Heart Association recommends you limit saturated fat intake to 7-10% of your total calories.
Monounsaturated fat includes canola, olive and peanut oils and avocados.
Trans fatty acids have hydrogen added to them to give them a longer shelf life and they also tend to lower HDL levels.
The American Heart Association recommends eating fish two times per week. Mention other fish that contain Omega 3 fatting acids. Omega 3 fatty acids are available as a supplement but research is till being done to determine the supplements’ effectiveness.
How can you stop cardiovascular disease? The heart healthy diet is designed to decrease sodium, saturated fat, including trans fatty acids which are all closely linked to high blood cholesterol and an increased risk of heart disease. It also encourages the increased intake of monounsaturated fat, Omega 3 fatty acids and soluble fiber which helps to lower blood cholesterol levels and reduce the risk of heart disease.
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.
International CHD mortality trends in men, 1968-2003 Source:BHF Heartstats (WHO statistics Men aged 35 - 74, Standardised)
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%)
Rapid Rise of Lifestyle related diseases in India ?
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.
Mismatch between our modern diet and lifestyle
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.
Socially we are people of the 21st centurybut genetically we remain citizens of thePaleolithic era (marked by the agriculturalrevolution 10,000 years ago).
Heart Disease in Indians (International Comparative Data)3x USA6x China20 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
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
India: A Capital of DiabetesEstimated number of diabetic subjects in India. Indian J Med Res 125, March 2007, pp 217-230
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 OtherSalim 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
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 OtherSalim 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
Progression of AtherosclerosisHealthy “Fibrofatty” Early Vulnerable Stable plaque artery stage lesion plaqueteenager Intima thickens, 50 year old atheromatous gruel forms under cap Lumen maintained Lumen narrows
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.
Types of cholesterol Lipoproteins- 4 main classes • Chylomicrons• Very low density lipoproteins (VLDL) • Low Density Lipoprotein (LDL) • High Density Lipoprotein (HDL)
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%
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.
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
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.
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.
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
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
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
Smoking is the leading cause of preventable death
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.
Smoking Is Related to Many Illnesses:• Respiratory System • Damages• Heart and Developing Fetus Circulatory System • Facial Wrinkling• Strokes• Eyes and Vision• Cancer• Osteoporosis
LACK OF PHYSICAL ACTIVITY 36% OF DEATHS FROM CAD IN MEN AND 38% IN WOMEN ARE D/T LACK OF PHYSICAL ACTIVITY
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
Need of the hour..– Education regarding the risk factors– Lifestyle therapy– Lipid lowering– BP lowering– Measures to improve treatment compliance
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.
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)
ATP III Dietary RecommendationsNutrient Recommended IntakeSaturated fat* <7% of total caloriesPolyunsaturated fat Up to 10% of total caloriesMonounsaturated fat Up to 20% of total caloriesTotal fat 25%–35% of total caloriesCarbohydrate (esp. complex carbs) 50%–60% of total caloriesFiber 20–30 g/dProtein ~15% of total caloriesCholesterol <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.
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.
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.
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
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 substituteSlogan – “One should drink milk till you drink your mother’s milk, afterthat we have no right to drink others milk”
Fruits & Vegetables5 servings of fruits & vegetables reduces heart attacks by 25-30%
Trans Fat & CAD Replacing 2% of Trans fat, lowers the Risk of Heart disease by 53%. Avoid over heating & reuse of oil
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 cholesterolcholesterol (LDL) q increases the risk of q Oxidises readily cardiovascular diseaseq reduces the risk of heartdisease and diabetes q Breaks down into potentially toxic substances during cooking
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
• 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
Comparison of Exercise and Antidepressants 25Beck’s Depression Index 20 15 Baseline 10 16 Weeks 5 0 Medication Exercise Blumenthal JA et al, Arch Intern Med 1999;159:2349
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
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 bodysurface area in meters.
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
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
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
Remember – we are predisposed3x USA6x China20 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
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
Why is eating “fast food” similar to smoking 2cigarettes? 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
Statins and CAD• Lots of evidence• Safe• Easily available• Need of the hour
Lack of Sleep Causes• Difficulties with memory and learning• Increased irritability• Accidents• Illness• Lack of energy• Stress• Weight gain• Rapid aging
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
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
Heart Attack• Common Myths – Gas / cervical• ECG can miss• Earliest treatment-Open artery as soon as possible• Time is muscle – saves lives