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The Rediff Interview/Dr Salim Yusuf, author of ground-breaking study
'By 2010, 60 % of world's heart patients will be in India'
May 29, 2008
The study, titled Create and conducted by Dr Yusuf, with Dr Denis Xavier of the St John's National Academy of Health Sciences, Bangalore, appeared recently in the prestigious British medical journal Lancet.
The study is a prospective registry study of almost 21,000 patients across India that concludes that Indians 'have a higher rate of serious heart disease at a younger age.' And, 'they are less likely to receive quick care than in other developed countries.'
In a telephone interview with rediff India Abroad Senior Editor Ajit Jain, Dr Yusuf called India the world's diabetic capital, where people are less active in their leisure time than any other ethnic group in the world. And contrary to our vegetarian pride, he said Indians' "consumption of fresh fruits and vegetables is low, compared to most countries."
We eat vegetables that have high levels of carbohydrates -- like potatoes, he pointed out. "And amongst wealthy people, their diet is highly oily and seriously wrong," he added.
In your study you conclude that within two years 60 per cent of the world's heart patients would be in India and it will hit more young people.
Yes. Three things are happening in India: People are eating richer food, more oily food, more fat food, and in India we eat lots of carbohydrates -- much more than most other parts of the world.
We are increasingly learning carbohydrates are bad for you as they increase the risk of diabetes, push down the levels of the good cholesterol. Our (Indian) genetics and lifestyle are (also) more prone to diabetes.
India is already the world capital on diabetes.
We seem to accumulate more fat in our abdomen. We don't know as yet whether this accumulation of fat is more genetic and/or because of our diet and the lifestyle. These things have to be found out.
The other thing is that in our leisure time we are less active than practically any other ethnic groups in the world. Our consumption of fruits and vegetables is low compared to most countries.
Is that true in rural areas as well?
Consumption of fruits and vegetables is low in both urban and rural areas. Although in rural areas people eat less meat and they are replacing it with carbohydrates. They eat more vegetables like potatoes.
Some of our studies in parts of India indicate they are not eating fresh green vegetables, fresh fruits. Even if they grow fruits and vegetables, they don't consume them; they sell them for money. And somehow our taste is in consuming very high amount of rice. The diet of wealthy people in India is highly oily.
So, between high caloric contents, increasing fat contents, less fruits and vegetables consumption, our diets are seriously wrong.
In urban areas, people have less physical activities. Of course, in rural areas people are quite active because of their manual work.
So, all these combined -- less physical activities, less consumption of fresh fruits and vegetables, more consumption of deep-fried food -- are leading to quite a bit of obesity. And it is a strange type of obesity, called central obesity, which is more damaging kind of obesity.
Smoking in India is not unusually high. There are lesser smokers in India than China. We (Indians) also have some different kinds of lipid abnormalities, which are more harmful. We can't be sure whether it is genetic or it is (because of the) diet, or lifestyle. So, we have a bunch of these risk factors that puts Indians at higher risks.
Why are younger people prone to heart diseases?
Obviously if you have more risk factors, the disease starts to strike you at a younger age. So, if you are at an intermediate level -- middle age or old age -- you may not get it at all, or you may get it at old age. If you have a high level of risk factors, they strike you at a young age.
Are people in India still not aware of these risk factors?
In India there's a lot of obesity amongst children in affluent families. So, increasing affluence is part of the problem. We are mal-adapting to the increasing affluence. Indians now use more cars and motorbikes than walk.
You can see photographs of families 30 to 40 years ago when they were thin. Now you see photographs of most fat people, families. You can see it practically in every home.
My grandfather walked practically everywhere. I don't think there were even buses when he grew up. Maybe he sat on a bus once or twice a year. Now I cannot think of my cousins, who live in villages, ever walking anywhere. Even when they are going round their properties in the village, they are on motorbikes. And you smoke lots of cigarettes.
So you are saying that increasing affluence in India has a negative component.
It does at initial stages. You are reacting to affluence. You now eat a lot of bad food. You are always in cars. And you smoke.
As you adjust to this affluence and more educated you are, you are starting to resist the bad effects. You tend to start adaptation and then start adjusting.
In a country like Canada, the affluent people have less heart disease compared to poor people. In a country like India, the affluent people have more heart disease compared to the poor people.
Would it not replicate in other countries like China?
How societal changes happen is going to be different from country to country. Food is highly culture specific. The Chinese eat with chopsticks. You can't scoop too much food with chopsticks unlike when you are eating by hands. Hands mean a much larger scoop.
The Chinese eat lots of fresh, lightly stir-fried vegetables. We Indians don't eat as much vegetables. So, there are these differences in food, fat content, etc, between the Indian and the Chinese, and the way the two peoples eat.
What happens when Indians migrate to North America? Do they carry their traits with them?
We do bring our traits, but we adopt Western styles. We also have mal-adaptation and urbanisation takes its toll. Twenty years back South Asians in Canada had the highest rate of heart diseases compared to other Asian groups. But then, as we started to learn to do the right things, heart disease among South Asians in Canada is now declining.
We have learnt how to deal with it. It is a good thing that we are learning how to deal with it. But the bad news is that the rate of heart disease among South Asians in Canada is still not as low as you want it to be.
In India the problem is compounded because of poor approach to healthcare. Most of healthcare in India is private and people there use a lot of high technology indiscriminately.
Practically, there's no preventive strategy. Even hospitals don't have a preventive strategy. When people get ill, and because they have to pay, poor people don't get as good care. Also, medicine in India is highly commercialised. So, a lot of money that's being spent is spent for the benefit of the people who deliver the care and not for the people who need the care.
In your study you say that in 2001, heart disease accounted for 7.1 million deaths worldwide, 80 percent of which were in low-income and middle-income countries.
Between 1990 and 2020, heart diseases are expected to increase by 137 percent for men and 120 percent for women in developing countries, compared with 30 percent to 60 percent in developed countries. By 2010, 60 percent of the world's heart disease burden is expected to occur in India.
With such alarming findings of your study, what is your advice for the Indian authorities and for Indians in general?
India needs a national strategy on prevention and on providing basic healthcare to everybody -- at either affordable costs, or even free. So, we need a governmental strategy, and on top of that individuals have a big responsibility to lead the right lifestyle.
I think health education is equally important. People should not allow children to pick up bad habits. The private sector also has an important role to play. It has to be a public-private partnership between the education system, families adopting it and activism at an individual level. So, it has to be a multi-pronged approach.
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