Prof. (Dr) D. Prabhakaran, MD, DM (Cardiology), MSc, FRCP, FNA, DSc (Honoris Causa), Executive Director, Centre for Chronic Disease Control stresses that data from around the world suggests that in recent decades, Indians account for a major share of early deaths, resulting from these three chronic diseases (Type 2 diabetes, heart attacks and stroke). Traditionally considered diseases of the elderly, these conditions are now increasingly striking younger populations in India
India, with a life expectancy of 72 years, (73.7 for males and 70.5 for females) ranks 126 out of 201 countries. It is at least 13 years lower than the leading countries of the WHO Global Life Expectancy Ranking.
This lower life expectancy among Indians is now largely due to the burgeoning chronic diseases In India arising from two contrasting reasons. First, the middle and high-income group individuals face the consequences of overconsumption, poor dietary choices that include high consumption of processed foods with high salt, sugar and trans fat content, and low physical activity. The poor, on the other hand, are burdened already with undernutrition and infections, have high prevalence of tobacco and alcohol use, high salt and carbohydrate, and low consumption of fruit and vegetable intake due to limited choices, all of which lead to increased risk for chronic diseases. In addition, overall Indians have a high propensity to diabetes and cardiovascular diseases which contribute to more than 50 per cent of all chronic disease deaths.
Data from around the world suggests that in recent decades, Indians account for a major share of early deaths, resulting from these three chronic diseases (Type 2 diabetes, heart attacks and stroke).
Traditionally considered diseases of the elderly, these conditions are now increasingly striking younger populations in India. Several studies have found common threads that link people of Indian origin with these diseases and thereby explain this phenomenon to some extent.
Exploring India’s cocktail of risk factors
Several factors intertwine to create this deadly cocktail of chronic illnesses that shatter dreams and ambitions of individuals, take a toll on caregivers and communities, burden an already strained healthcare system and cast a long shadow on India’s social, economic and demographic fabric. These include:
Rapid urbanisation: As India becomes more and more urbanised, traditional lifestyles have made way for sedentary routines. Where people once used to walk or take a bicycle, more mechanised modes of transport that require less exertion have taken over. Escalators and lifts have replaced steps and stairways. Entertainment can be found at the click of a button and the preferred workplaces are the ones that have lazy boy recliners and nap pods. This shift in lifestyle fuels obesity, a significant risk factor for all three diseases. In addition, the chaotic urbanisation has resulted in the proliferation of slums which house recent rural migrants. Several studies have shown that these rural migrants within 10 years of migration acquire risk factors akin to their original urban counterparts without necessarily becoming affluent.
Changing food habits: India has witnessed a sea change in its food habits. Fast and processed foods have taken over fresh foods. A large population of young Indians are growing up on an unhealthy diet of processed food, and ready-to-cook meals which contain preservatives. Both Indian and westernised foods laden with sugar, unhealthy fats and refined carbohydrates are available easily, in a wide range of options, at your doorstep, in a matter of minutes. However, they almost always come at the cost of the fibre-rich, protein-balanced, millet based traditional meals that have sustained Indians for generations. This dietary imbalance plays a crucial role in the rise of diabetes and CVD.
Substance abuse: According to the Foundation for a Smoke-Free World, India with 267 million tobacco users, is the country with the second-highest number of tobacco users in the world. Associated with increasing the risk of heart attacks smoking also increases the risk of stroke by narrowing blood vessels and promoting the formation of plaque and clots.What is more, the chemicals present in cigarette smoke are known to weaken the arteries, making them more susceptible to a tear, thereby leading to a haemorrhagic stroke and ballooning of the aorta called aortic aneurysm. In addition, it can result in gangrene due to blockage of blood supply to the upper and lower limbs.
Genetic predisposition: It has been customary to blame the genes for the higher predisposition to CVD and diabetes. While there is preliminary evidence that genes may play a role particularly in Type II diabetes, a high risk gene is not necessarily the trigger for a heart attack or stroke. The triggers are lifestyle practices and the gene-environment interaction is an area of intense research now. Genetic abnormalities alone causing heart attacks or strokes are rare and perhaps contribute to less than 10 per cent of all heart attacks and strokes.
Socioeconomic inequities: Access to modern healthcare, proper nourishment and preventive education varies across socioeconomic groups. This disparity sets in motion a vicious cycle, where the most vulnerable are also the most at risk. For a vast majority of the population that is struggling to make ends meet, the system offers overcrowded public hospitals, limited services and long wait times. People who are juggling daily wages and family responsibilities can ill afford the luxury of high quality healthcare and for them, the golden-hour rule which is critical for saving lives in the case of a heart attack or stroke is a pipe dream. Ultimately, even minor symptoms go unchecked and snowball into serious consequences down the line.
Environmental pollutants: Pollutants like fine particulate matter, pesticides, vehicular pollution, CO2 and heavy metals are increasingly linked to a surge in cardiovascular diseases, stroke and diabetes. These silent toxins trigger inflammation, disrupt insulin signalling and damage blood vessels, paving the way for chronic medical conditions.
The prohibitive cost of healthcare: The crippling cost of healthcare casts yet another long shadow on managing chronic diseases. Most often, the fear of exorbitant medical bills leads to delayed medical attention, ignoring early symptoms and postponing crucial screenings. By the time of diagnosis, the disease often progresses to a late stage, significantly reducing the effectiveness of treatment and opening the door to severe complications. Add to this, expensive medicines that need to be taken life-long, specialized therapies, and surgical procedures and you are left with insurmountable hurdles. In itself, it can be the cause of stress, which can trigger further complications.
The role of emerging infections: While traditional enemies such as unhealthy lifestyles and genetics hold their ground, fresh hindrances to good health such as viral and bacterial invaders are increasingly triggering and aggravating, chronic diseases. For example, certain kinds of influenza can mimic a heart attack and gut bacteria that is linked to gum disease can disrupt insulin signalling. Even COVID-19 can worsen a patient’s condition by impairing insulin resistance and directly attacking pancreatic beta cells.
While various hypotheses have been explored to understand the level at which the above-listed risk factors impact Indians, as opposed to other ethnic groups, research is increasingly pointing to the role of inherent biological differences, such as lipid and glucose metabolism, inflammatory states, genetic predispositions, and epigenetic influences, contributing to an increased risk of chronic diseases.
While the picture is still unravelling with new challenges coming in as fast as new solutions, more research is needed to fully understand these complex interactions. However, one thing is certain: for India to gain solid ground in its fight against chronic disease, a holistic approach is required – one that considers both traditional and emerging risk factors as crucial for effectively preventing, managing, and ultimately conquering these chronic conditions. Policies to promote healthy habits (examples include tobacco and alcohol control measures), harnessing the power of digital health, innovative redesign of health care and simplifying care pathways including fixed dose combination are some examples.