Jump to content

Indian Predisposition To Heart Attacks


Recommended Posts

Having seen a few of the older generation have heart attacks (in both family and the family of close friends), I think we as brown people need to accept that there is something behind the much higher rates of cardiovascular disease amongst us compared to other communities. It can't always be explained away simply by poor lifestyle choices from what I've seen. I found this piece containing a lot of interesting ideas from a US based Indian specialist in the area, well worth a 'butcher's hook'. Suffice to say, it appears as if we have to be a bit more careful of some things due to genetic dispositions.

Opinions welcome.



Dr. Enas A. Enas:

"While Your Genes May Have Loaded the Gun,

It’s the Life Style Choices That Pull The Trigger."

By Kavita Chhibber

As a first year medical resident in Chicago in the early 1970s, he saw a 22 year old fellow resident from his home state of Kerala have a heart attack and die 15 years later, still waiting for a heart transplant. It was a pattern that was to repeat itself over many years before his eyes-young Keralite physicians, living relatively healthy life styles, falling prey to heart disease at relatively young ages.

Today renowned cardiologist Dr Enas A. Enas, has proved that Indians are the only immigrant community that continues generation after generation to have heart disease almost 10 years ahead of other racial groups. While deaths from heart disease have fallen by more than 40 percent in all racial groups, it remains high amongst South Asian men and women world wide and has exploded in India.

In an exclusive interview with Kavita Chhibber, the man who has made educating Indians about heart disease in the hope of eradicating it within the community, his life’s mission, talks about the breakthrough he made in solving a cardiac jigsaw puzzle that baffled him for more than 2 decades, and why its time that South Asians stopped hiding behind the line-its all in my karma.

So why did you choose medicine over any other career?

When I was 15 or 16, I saw my mother dying of complications of pregnancy. There was no doctor around for miles in or near my remote village in Kerala, and it strengthened my resolve to study medicine. My father has been my greatest inspiration. He was a man who had only a 5th grade education but he taught me one key lesson-you never stop learning and you must never stop sharing your knowledge with others. He continued to mentor, guide and help me. He was the overwhelming force behind my drive to succeed.

I was always a good student and got admission in medical school on my own merit, at a time when there were no good schools around. Even the medical college was about 20 miles away from my home.

I finished medical school in the minimal number of years required and while every one else was planning to go to UK, for further medical studies, I chose the US, because at that time cardiology was just emerging as a specialty and to the best of my knowledge there was no cardiologist in Kerala at that time. So I decided to go to the US and gain as much knowledge as I could in cardiology.

I came to the US in 1970, straight to Chicago and that is where I have stayed since then.

What was your first impression of the US?

My wife Mary and I left India with 8 dollars between us. At Paris we mistakenly ate some food around 5 p.m. and were not compensated by the airlines that informed us it was not lunch time but tea time for them, so by the time we landed in Chicago I had 2 dollars left. Luckily my wife’s brother lived in Chicago so mercifully we were saved!

I think all of us who had come here in the 70s were equipped with a lot of theoretical knowledge of medicine but back home we didn’t have the luxury of confirming whether those theories were applicable and whether they indeed gave the desired results. Within a week of coming here I saw some one receiving a pacemaker. Until then I had only heard of one. Again in India if someone had a heart attack and we needed to do an electrocardiogram, it took 24 hours to get the machinery from another floor and then do it. Here I saw it being done within 5 minutes of being ordered. It was impressive to see how fast and efficient the system was out here, how quickly everything could be diagnosed which ensured the best possible care for the patient.

Heart disease in the 70s was probably considered the disease of the old. But you noticed something that perturbed you

When I was a first year resident I saw a fellow resident from Kerala who was 22 years old come to the hospital four days in a row with chest pains. On the fourth day he was admitted to the hospital. This was a shocking experience for me-to see someone also from Kerala with heart disease at such a young age. He waited for 15 years to receive a heart transplant and died waiting.

Then again as a second year resident, another very close friend, with whom I alternated rounds, was admitted to hospital after a heart attack and I was called in to replace him. Then my own brother in law had heart bypass surgery at 45, and had to retire at a young age. This pattern was something I continued to see even after I got into private practice. I wanted to unravel the mystery but being in private practice meant I really couldn’t do research work. When I approached my physician friends in academia, they were skeptical and said Indians have the same number of heart attacks as anyone else-heart disease is heart disease-there is nothing different about Indians.

But I just couldn’t let it go. Later I became the President of the Kerala Medical Doctors Association, and then the Treasurer with AAPI--and as I talked across the board with hundreds of physicians in USA the same pattern emerged. Many of these physicians led a healthy life style, didn’t smoke, exercised regularly but kept getting heart attacks at young ages. Many of these were internists and cardiologists-the teachers and preachers for heart disease. They had access to the best knowledge, the best health care, the most advanced medicine, but here they were, having heart attacks. Then another close friend who was Chief of psychiatry, had a heart attack at 39, and the heart disease increased so rapidly that it became inoperable within four years.

There has been a global phenomenon of high heart attack rates among Indians. It has been reported from 1954 onwards. In fact in 1954 a husband wife team Dr Dhanraj and Dhanraj reported that autopsies done on 10,000 Indians in Singapore showed that heart disease was seven times more common in Indians than it was in say the Chinese population there. While we could attribute the heart disease to the fact that most Indians who came to Singapore were from the lower social strata and thus lacked the knowledge to take care of themselves, finding the same thing in top physicians and also the fact that they had a 10% rate as far as heart disease was concerned compared to 3% in American doctors was again a cause for concern. And this time these were physicians who were not obese, were exercising and eating right, and were non smokers. That was the big shocker.

Just think about the average Indian who smoked, and didn’t exercise and lived a sedentary life style. Every one of those Indians was a catastrophe in the making.

But for me the key turning point came when Dr Sudarshan Sadhashivam, the Dean of one of the top medical colleges in Tamil Nadu came to visit his new born grand daughter in the US. He had taught my brother in law so he came to visit me as well. This was a man who was an epitome of what would be considered perfect health. He also had what would be considered ideal habits. He was a vegetarian, exercised 2 hours daily, ate lots of fruits and vegetables, and wasn’t stressed out.

Yet sitting in my office that day, he had not one but two heart attacks. That was the day I told my wife Mary, that I was going to unravel the enigma of heart disease from this Professor’s blood and his arteries. He had the most severe heart disease even after having done everything to live a healthy life style. When I studied his case I found that while he had low HDL about 32mg/Dl-his lipid profile was considered normal. But what intrigued me was the fact that he had a high level of something called lipoprotein(a) which measured at 42mg/Dl. This was the key. L-P Little-(a) is one of the most widespread and important emerging risk factors for premature heart disease. High levels of LP (a) are found in more than 40 percent of Indians as compared to 20 percent of whites for example. LP(a) has an abnormal protein attached to it and it rapidly promotes plaque build up and abnormal blood clotting, the two most key factors causing heart attacks.

So that seemed to be the key reason why many Indians had early heart attacks in spite of leading seemingly healthy life styles. The LP(a) is a genetic deviant and so if you have a genetic predisposition for it, it puts you at a much higher risk for heart attacks than someone who doesn’t have it.

My discovery was still met with skepticism. Just because I found it in 15-20 people didn’t mean it was applicable to the entire South Asian population. So then we did a study of about 500-1000 people across Chicago and Canada and found that 1 out of every 3 Indians had this LP (a). In simple terms LP(a) is ten times more dangerous than regular LDL. 20 mg of LP(a) acts as 300 mg of cholesterol, and sadly it starts plugging the arteries by age 2, and not 20. One cigarette pack becomes equal to 3 for an Indian smoker with LP(a).

My message to Indians and the medical and health insurance communities is that Indians are different and their medical needs are different. They cannot be lumped in the same category as everyone else when it comes to heart disease. In UK they are already treating Indians differently. They have recognized this fact. If they don’t their health care system will break down under the extensive number of angioplasties and other treatments they will end up doing.

Today even on the AAPI website you will see that the guidelines for Indians are different.

This is what it says.

Target Numbers for Indian Americans to achieve, to prevent Coronary Artery Disease:

Non HDL-C should be less than 130 mg/dl .For an American 160 mg/dl is acceptable.

(Total Cholesterol-HDL= Non HDL-C)

LDL-C should be less than 100 mg/dl

HDL-C should be more than 40 mg/dl for males and more than 50 mg/dl for females

If a person has Diabetes or Coronary Artery Disease non-HDL-C should be less than 100 mg/dl and LDL-C less than 70 mg/dl

If a person has Diabetes, A1c should be less than 6.5

Waist Circumference should be less than 35 inches for men and less than 31 inches for women

Quit Smoking

Blood pressure less than 140/80 mm, 120/80 mm if you are a diabetic.

What can most Indians do in terms of preventive care? There are several diets on the market and those like the Atkins diet which is predominantly meat oriented is even tougher for many Indian vegetarians.

Life style is key. I always say that while genetics loads the gun, it’s the lifestyle that pulls the trigger. Indians don’t eat well. When an American or a European needs fried food they go to the fast food restaurant. What do Indians do? They make fried foods at home and start feeding their kids very early on. So the Indian kids eat fried food at home and then go out and eat fast food so it’s a double whammy.

I tell everyone, don’t get into these branded diets. The bottom line is- a calorie is a calorie is a calorie. Get your blood work done and if you have a high LP (a) and other problems fix it. Exercise regularly, eat nuts fruits and vegetables and foods that are not over fried.

The fact remains that heart disease today is the most predictable, preventable disease. In 1910 heart disease was almost unheard of in the US. Between 1910-1960, it increased five fold, but from 1968 to 2000, it had come down by 60 percent. Many developed countries saw the same drop. How did they achieve that? By educating and treating people.

Today in India heart disease is the leading cause of death. In 2000 there were 27 million people with coronary artery disease. This is projected to go up to 64 million by 2015-an astronomical number. Today, just like in the case of the AIDS epidemic the Indian government has finally accepted that there is an epidemic of coronary heart disease among Indians and they need to take action. I’m going to India this month and will be crisscrossing across the nation educating doctors about this. A pilot project in heart disease prevention has been launched in Bihar and Andhra Pradesh as well.

Coronary heart disease amongst Indians with LP(a) begins at 2 and not 20 so there is no need to be surprised when someone has a heart attack at 30.

Another thing that irritates me is this fatalistic belief in Karma. A friend of mine who does angioplasty day in and day out has an unhealthy lifestyle but refuses to take care of himself or get himself checked. He says when my time comes I will go. Its my karma.

How is it that when comes to finding the perfect match for their kids or that Ivy league school for their kids Indians don’t go by karma then?

Its time we stopped hiding behind what is supposedly our destiny and took charge of our health. Get to know your numbers as early as possible and watch them carefully.

I think the biggest beneficiary of this research has been me. It forced me to change my own lifestyle about 15 years ago. When I came to this country I was thin and fit. Within six months I too had packed on the pounds. I finally made a conscious effort to lose weight or I’d be dead and gone by now. I exercise every day, I take my medicine, watch what I eat and make sure all my numbers are the best possible that can be.

What about South Asian women ? Most women feel that they are protected by estrogen prior to menopause so they don’t have to worry about heart disease.

Unfortunately South Asian women are as much if not more at risk for heart disease as Indian men. On an average a pre-menopausal white woman has HDL levels that are about 10 mg higher than their male counterpart. The Indian woman is an exception. Her HDL level is as low as Indian men and she too has the LP deviant LP(a). In fact there was a provocative study done by Dr. Latha Palaniappan, from 1990-2000 in California on six ethnic groups - non-Hispanic white (white), Hispanic, non-Hispanic black (black), Chinese, Japanese, and Asian Indian Americans. The report said that “All sex-ethnic groups showed a decline in all cause and CHD mortality compared with the period between 1985 and 1990, except Asian Indian women, who experienced a 16% increase in all cause mortality and 5% increase in CHD mortality.”

Women have never perceived heart disease as a problem and until they do and modify their life styles accordingly, it is going to become a huge problem. Preventive care amongst Indians has to start 20 years sooner than that of Caucasians.

Let’s talk about your book How To Beat The Heart Disease Epidemic Among South Asians - A Prevention and Management Guide for Asian Indians and their Doctors

I think after years of research I felt the time had come for a book like this. The epidemic of heart disease raging in the Indian subcontinent is deadly and what is worse, a silent one. For the past 15 years, I have maintained a laser-like focus on this tsunami of heart disease sweeping people from the Indian sub-continent in its sway, drawing attention to it through research, journal publishing, and about 100 speaking engagements a year. Gradually medical professionals, both Indian and non Indian have become familiar with this massive problem. The public, especially the Indian public barely knows about it. This book will help them take a long look at themselves, their dietary habits and equip them with information to ask questions of their physicians.

This book is aimed at stemming and reversing the tide. I can’t say this enough - heart disease is highly predictable, preventable, treatable and even reversible. Read this book and then work with your doctor, make appropriate life style changes and take medications if you need to.

Today we have enough knowledge to reduce most people’s heart disease risks to surprisingly low levels-but people must grasp the urgency of the need to do this, and translate the urgency into practical preventive action.

Edited by dalsingh101
Link to comment
Share on other sites

  • 6 months later...

Very interesting article. Thanks for sharing it!

What can most Indians do in terms of preventive care? There are several diets on the market and those like the Atkins diet which is predominantly meat oriented is even tougher for many Indian vegetarians.

Life style is key. I always say that while genetics loads the gun, it’s the lifestyle that pulls the trigger. Indians don’t eat well. When an American or a European needs fried food they go to the fast food restaurant. What do Indians do? They make fried foods at home and start feeding their kids very early on. So the Indian kids eat fried food at home and then go out and eat fast food so it’s a double whammy.

I tell everyone, don’t get into these branded diets. The bottom line is- a calorie is a calorie is a calorie. Get your blood work done and if you have a high LP (a) and other problems fix it. Exercise regularly, eat nuts fruits and vegetables and foods that are not over fried.

Link to comment
Share on other sites

  • 2 years later...

Join the conversation

You can post now and register later. If you have an account, sign in now to post with your account.
Note: Your post will require moderator approval before it will be visible.

Reply to this topic...

×   Pasted as rich text.   Paste as plain text instead

  Only 75 emoji are allowed.

×   Your link has been automatically embedded.   Display as a link instead

×   Your previous content has been restored.   Clear editor

×   You cannot paste images directly. Upload or insert images from URL.

  • Create New...