The Epidemic of Heart Disease in the Indian Subcontinent
The rich and noble history of Hyderabad has led the Indian government to recognize the city as one of the most important heritage sites in all India. Since medieval times the banquets and food of the Deccan have been legendary—perhaps second only to Lahore. Recently, however, Hyderabad has gained a new title: the diabetes capital of the world, with more diabetics as a percentage of population than anywhere. One in every six people above the age of twenty-five is diabetic; over the next five years this is predicted to rise to one in three people. Doctors at the Nizam’s Institute of Medical Sciences predict that half of all Hyderabadis will develop diabetes over the next ten years. This epidemic of diabetes is not limited to the Deccan. Hyderabad might be the capital city of diabetes, but India has more people with diabetes than anywhere in the entire world. And the problem is only getting worse.
The problem with diabetes is that it usually leads to other more serious diseases, such as heart disease. Just a few decades ago the only people in India who died from a broken heart were the heroes and heroines in a classic Bollywood film. Now, coronary heart disease has reached epidemic proportions in India, with fully 70% of the population—that’s around 840 million people—at risk. But it’s not just the ridiculous number of people with heart disease, it’s that their average age is getting lower. Just this month the Times of India reported that 58% of heart disease cases occur under the age of forty. An astonishing 30% are under thirty years old. And lest any Pakistanis, Bangladeshis, or Westerners of Indian subcontinent descent are thinking none of this applies to them, it does. In fact if you’re from the Indian subcontinent then you have a three to four higher chance of heart disease than a white American or European, a six times higher chance than the Chinese, and twenty times higher risk than the Japanese.
High blood pressure is also more prevalent among Indians and Pakistanis. Around 40% of urban Indians and between one-third and one-half of Pakistanis over the age of forty-five have high blood pressure. If you have high blood pressure, if your arteries are constricted, if you are prediabetic or diabetic, if you have heart disease, then eventually you’ll have a heart attack. Here’s what happens when you have a heart attack.
First, fatty deposits build up in your arteries. With the arteries shrunk, blood struggles to reach the heart and brain, then clots form. One of the first signs something is wrong might be a soreness on the inside of your spine, a soreness that will not go away. Your back feels tense. It feels wrong. Then your chest starts to feel tender, you might rub it and leave a red mark on the skin, then push on it to release the tension. Now imagine someone has got a thick leather belt, the sort with a buckle on, and put it over your head. They slide the belt over your shoulders, over your upper arms, around your chest, then start to pull on the belt, making it tighter and tighter. Your chest is constricted. It really hurts. Then they fasten the belt, and leave it there, tight, constricting, you’re unable to breathe. This is what a heart attack feels like.
In this state a doctor might sedate you, then open up your upper leg near the groin, and seek an artery. While you’re still awake, while your chest feels like it’s being crushed by a tightened belt, a small mesh tube called a stent is threaded up the artery from the leg, ever upwards through your body, and laid to rest near your heart, so that the blood can flow once again. Or you might be shocked with electricity, or have a heart bypass, wherein a blood vessel is taken from one part of the body and grafted onto the coronary artery.
Or you might just die.
Before the age of forty-five.
It wasn’t always this way in India.
Ancient Ayurveda medical texts make little to no mention of heart disease, suggesting that Ayurvedic doctors seldom, if ever, came across it. However, a number of key events converged in the 1950s, affecting Indian health until the present day. The first event was the profiteering of the giant Anglo-Dutch company Unilever. Before the 1950s India cooked with small amounts of butter ghee, until Unilever developed a hydrogenated vegetable oil ghee called Dalda. What followed was a deliberate plan to replace butter ghee with Dalda throughout India, using Indian housewives, a vigorous marketing plan, and catchy Bollywood-style songs easily remembered by children. The campaign was wildly successful. Unilever made a pile of money, butter ghee was replaced with vegetable oil, everyone knew the word Dalda, and then it was discovered that the trans fats in vegetable oil ghee cause heart disease.
The second event was the 1951 Green Revolution that sought to avoid reliance on foreign food aid by growing inexpensive crops. Unfortunately, the crops promoted were not traditionally a major part of the Indian diet, and some, like white flour, trigger Type 2 diabetes. In contrast, the traditional grains of India, consumed for over 3,000 years, when rates of heart disease were low, were amaranth (rajgira), barley (jau), millet (bajra), sorghum (jowar). Rice was also eaten, but the portion size was much smaller.
The final big change was a move towards an urban lifestyle. This brought a decrease in physical activity, a huge rise in meat consumption, increased stress, the intake of high-energy foods, a desire for Western foods and meals eaten outside the home, and the frequent eating of rich foods otherwise only eaten on special occasions. Doctors in Hyderabad attribute much diabetes to this pattern of city living, and add that late-night eating is now further worsening health.
Put these big changes together, then add them to the genes found in people from the Indian subcontinent, and you have rampant diabetes and out-of-control heart disease. Because here’s the thing: people from the Indian subcontinent have lower levels of vitamin B12 and lower levels of folate, which leads to a build up in the body of the amino acid homocysteine. Homocysteine is a significant cause of heart disease and Alzheimer’s disease, as it causes inflammation and atherosclerosis, and encourages unhealthy LDL cholesterol. Indians tend to have higher levels of homocysteine than other nations. Add this to an already long list of risk factors and people will die in their forties—and that is exactly what is happening.
So first the good news. Absolutely do not adopt a Western-style health diet, do carry on eating as many spices and herbs as you possibly can, especially turmeric (haldi). Chew on turmeric, put it in food, put it in milk, have it every day if you can, the same with ginger. However, the bad news is that you’re going to have to start moving—you’re going to have to exercise.
Here’s some recommendations taken from the Indian Heart Association that can reduce your risk of heart disease by 90%.
- Stop chewing tobacco or paan. According to the Indian Heart Association this is the number one preventable risk in India. Around 50% of Indian men chew paan at some time. Even chewing it once for ten minutes constricts arteries by 14%.
- As Hyderabad and India have a problem with diabetes you have to stop eating sugar, desserts, fruit drinks, fizzy drinks, and junk food, saving them for rare treats. Eating ras malai is over.
- Minimize fried food and reduce fat in your diet. Eat home-cooked food, not street or restaurant food. The fat to use is butter ghee, but in very small amounts as Indians do less well on fat than other people. Do not reuse oil.
- Avoid white carbohydrates such as white flour. Use the grains that were used on the Indian subcontinent for thousands of years: amaranth (rajgira), barley (jau), millet (bajra), sorghum (jowar). Punjabis are probably going to be fine with wheat chapati, but use wholegrain wheat. Rice eaters should remember that the old serving size of rice in India, China, and Japan was half a cup, not a laden plate.
- Do not drink coffee. It elevates homocysteine.
- Eat lots of fresh, local vegetables, fruits, and plant foods as the main part of your diet, especially green vegetables, which should be cooked with little to no oil, though they can be made desi style. Dal (lentils) are excellent.
- Eat meat sometimes, it’s essential for vitamin B12, but in small amounts. You don’t need huge chunks every day. Too much meat and too little meat can both raise homocysteine. Therefore, a balance is needed. If you come from an area where people eat fish then eat fish.
- Reduce blood pressure. This is done by reducing salt and eating less pickled food (achar).
- If able, take a vitamin B complex that includes folic acid. It’s possibly the most important supplement for many people to take as it gets rid of homocysteine and wards off dementia.
- Have a happy marriage and family. University of Michigan researchers found that a bad marriage physically stresses your heart, more so as you get older. So stay in love with your sweetheart.
- Lose weight. Indians need a BMI of 22 or under, rather than under 25.
- And to lose weight you’re going to have to exercise.
Exercise is one of the most important things you can do to avoid heart disease. Yet a recent Indian study found 79% of men and 83% of women to be inactive, with lack of exercise more common among the most educated. Another Indian study found that briskly walking forty minutes per day reduced heart disease by 55%. This is the first step, start moving, start walking, stop sitting, stop travelling by car if you can walk. Once you’ve improved your diet, lost weight, and you’re walking daily, then you can start thinking about other more intense forms of exercise. The most important thing is to do something you enjoy, that raises your heart rate, and you can do almost every day. India has a long tradition of bodyweight exercises, at some point add these in. Eventually you’re aiming for thirty minutes of exercise, five days a week, with frequent walking on top. These recommendations are for men and women.
To summarize, have a happy family life, eat real, old-fashioned, simple Indian food, not too much, nor the food of kings, eat mainly food from plants, lose weight, move about frequently, raise your heart rate, sit little, get strong, and go to bed early.