Chapter-1

Introduction
 CHAPTER – 1
INTRODUCTION

1.1 CORONARY HEART DISEASE (CHD)

1.2 RISK FACTORS OF CORONARY HEART DISEASES
1.2.1 Modifiable risk factors
1.2.1.i Age
1.2.1.ii Gender
1.2.1.iii Family history
1.2.2 Non-modifiable risk factors
1.2.2.i Obesity
1.2.2.ii Dyslipidemia
1.2.2.iii Diabetes
1.2.2.iv Hypertension
1.2.2.v Unhealthy diet
1.2.2.vi Tobacco-smoking
1.2.2.vii Harmful use of alcohol
1.2.2.viii Lack of physical activity
1.2.2.ix Psychological stress
1.3 CONSEQUENCES OF CORONARY HEART DISEASE
1.3.1 Angina pectoris
1.3.2 Arrhythmia
1.3.3 Myocardial Infarction
1.3.4 Heart failure
1.4 PREVENTION OF CORONARY HEART DISEASE
1.4.1 Intervention for prevention of CHD
1.4.1.i Diet and lifestyle intervention
1.4.1.ii Intervention for increasing knowledge about the
modifiable risk factors
1.5 SIGNIFICANCE OF THE STUDY
1.6 OBJECTIVES OF THE STUDY

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 Introduction

1.1 CORONARY HEART DISEASE (CHD)

Coronary heart disease (CHD), also known as ischemic heart disease (IHD),
is the leading cause of heart failure in India. According to the first National Heart
Failure Registry of India, released in Kerala, June 2020, the rate of dying within 90
days of occurrence of the event of heart failure is 17 per cent, which is quite high
when compared to the other non-communicable diseases. The reported findings also
draw attention to the fact that the disease burden is more prevalent among people
below 65 years of age in India than in other countries. Further, the report highlighted
that most of the heart failures, manifested with reduced Ejection Fraction, i.e.,
reduced pumping function of heart is due to the weakness of the heart muscle. The
etiology of heart failure revealed that 73 per cent of it to be caused by CHD, 17.2
per cent by dilated cardiomyopathy and 5.9 per cent by rheumatic heart disease
(RHD). Most frequent co-morbid conditions of heart failure are hypertension and
diabetes (48.5 per cent and 44.4 per cent, respectively) (Times of India, 2020).

Heart disease is the term used for all types of conditions affecting the
structure or functions of the heart. Coronary heart disease is also known as Coronary
artery disease (obstructive and non-obstructive), Ischemic heart disease, Coronary
syndrome-X and Coronary microvascular disease. CHD is caused when the arteries
supplying blood to the heart are unable to deliver enough blood to the heart
mu\scles. It is mostly caused by the process of Atherosclerosis i.e., building up of
plaque, a waxy substance, under the lining of large coronary arteries. This plaque
blocks the blood flow towards heart, partially or totally, and the condition is caused
by a disease, injury or lack of oxygen, affecting the function of arteries supplying
blood to the heart. Coronary microvascular disease occurs when the tiny blood
vessels of heart function abnormally (National Heart, Lung and Blood Institute
[NHLBI], 2021).

Garcia-Covarrubias et al. (2018) defined CHD as a complex pathological

condition that may be defined by an inadequate oxygen supply to the myocardial
cells. The coronary vessels involved in atherosclerotic process show lipid
accumulation and chronic inflammation. Sometimes the atherosclerotic plaques in
epicardial vessels rupture and lead to thrombosis, which may manifest as fatal
Myocardial ischemia followed by Myocardial infarction.

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STAGE5 ‘The age of inactivity and obesity’: This stage is due to modern
epidemics of diabetes, obesity, hypertension and dyslipidemia, due to which CVD
death rate increases. The major reason behind all the lifestyle diseases is lack of
physical activity and faulty dietary habits.

According to Kuate-Defo (2014), in the early 20th century, the increase in

CVD deaths in the developed world, especially European countries and North
America, marked the presence of this fifth transitional stage in effect of
industrialization and urbanization, which lead to modern lifestyle of physical
inactivity. This stage hit the developing countries like, India fifty years later towards
the end of 20th century.

Dorairaj et al. (2016) pointed that this ‘epidemiological transition’ from era
of communicable diseases to non-communicable and that too, CVD as most
prominent cause of death, that has occurred at a fast pace. They also acknowledged
the heterogeneous nature of prevalence of cardiovascular risk factors in India.
Though, emergence of CVD, as major cause of death in all regions of India, is
established but particular cause of concern is its accelerated build up, premature
onset and high case fatality rate. Since 1990 to 2010 there has been 59 per cent
increase in premature mortality due to CVD in the country. It has risen from 23.2
million in 1990s to 37 million in 2010.

Misra et al. (2011) studied the epidemic of diet related non-communicable

diseases and its socio-economic burden on the country. He reported that India
underwent a ‘Nutritional Transition’ from 1973-2004, mostly as a product of
urbanisation. They reported nutritional trends as given below:
• A 6 per cent increase in calorie intake from fats and 7 per cent decrease in
carbohydrate intake.
• An increasing intake of salt, meat and meat products.
• A decreasing intake of coarse cereals, pulses, fruits and vegetables.
• Decline in physical activity.
• Escalation in levels of subclinical inflammation, obesity, atherogenic
dyslipidemia, metabolic syndrome, type 2 diabetes and CHD.

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The reasons for higher prevalence of CHD in India have been traced to
prenatal and perinatal events like, maternal nutritional deprivation. The deficiency
in maternal nutrition leads to low birth weight in child. The child who is born having
less weight has shown high incidence of NCDs in the early adulthood. The
association of low birth weight, which is very common in India, has led to increase
in risk factors of CHD like, hypertension, type2 diabetes, etc. These adults also
develop CHD in young age and are more susceptible than normal weight adults. The
catching up of growth in early childhood makes Indian population vulnerable to
obesity and glucose intolerance, thereby make the Indian adults more prone to
develop CHD at younger age (Misra et al., 2011).

1.2 RISK FACTORS OF CORONARY HEART DISEASES

The risk factors of a disease are the underlying factors contributing towards
the development of any particular disease e.g. tobacco abuse, which is a major risk
factor of CHD.

The risk factors of coronary heart disease are categorized in two: the non-
modifiable and the modifiable. The non-modifiable risk factors cannot be changed
with any of the prevention or treatment technique. The modifiable risk factors can be
changed or modified with prevention and treatment techniques.

Non-modifiable risk factors: age, gender and family history.

Modifiable risk factors: obesity, dyslipidemia, diabetes, hypertension, unhealthy

diet, tobacco smoking, harmful use of alcohol, lack of physical activity and
psychological stress.

1.2.1 Non-modifiable risk factors

The risk factors which cannot be modified or changed are non-modifiable
risk factors. These are discussed below.

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1.2.1.i Age
The normal degenerative changes with aging have shown drastic effect on
functioning of vital organs. The heart too, shows the degenerative changes, viz.
valves and vessels involved in flow of blood get stiffened and loose elasticity with
the passage of time. The walls of the capillaries become thick hampering the
exchange of nutrients and oxygen. Due to the thickening of walls, the ventricle
chamber’s actual blood holding capacity decreases but the size increases. This leads
to slowing up of heart rate (arrhythmia) and fibrillation. The increase in the
oxidative stress, pave way to the apoptosis resulting in cardiac remodelling, altering
the structural and electrical mechanisms related to functioning of heart leading to
atherosclerosis (Rodgers et al., 2019).Though a non-modifiable risk factor, age is
still an independent risk factor for CHD (Dhingra &Vasan, 2012).

1.2.1.ii Gender
The symptoms and prevalence of CHD are different in women before the age
of 65 years, after that the women too, are equally at risk. The gender differences in
prevalence of CHD are observed in many studies. The predisposition of male gender
to the risk of the CHD has been shown in studies related to CHD prevalence. The
males have shown higher mortality especially, at young age as compared to women.
The occurrence of CHD in males is observed at least 7 to 10 years earlier than the
females (Maas &Appelman, 2010).The female hormones like, oestrogen shows a
protective effect on women against CHD. The biological differences in the arterial
wall of women also delay the manifestation of CHD in them (Bajaj et al., 2016).

1.2.1.iii Family history

If a family member or the first relative has CHD at age less than 55 years for
male and 65 years for female, it is called family history of CHD. At molecular level,
CHD develops through a collaborative effect of in gene products and environmental
insult. Heianza and Lu (2019) and Talmud (2007) reviewed the role of gene-
environmental interaction and its impact on CHD risk. According to them, subjects
having high risk genotype when exposed to the high risk environment like, high
intake of dietary fat, smoking, alcohol consumption and physical inactivity are more
at risk of developing CHD. They suggested that genetic risk can be modified by

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making the changes in the environment in a specific manner. A person having

genetic predisposition of CHD when comes in contact with environmental hazards
like, passive smoking or pollution is more likely to have a CHD event in comparison
to another person having no genetic predisposition, being exposed to similar
risks. This explains the difference in risk profile of individuals exposed to similar
environment factors like, cigarette smoke and further lay foundation for need of
environmental modification to control the risk factors. It is known that CHD is
modified by genetic, as well as, environmental factors. They provided an insight to
pathological understanding of CHD risk and emphasized upon identifying persons at
high risk to advise them specific therapies based on their risk and demonstrated how
the gene-environment interactions have multiplicative effect on CHD risk.The role
of genetic endowment seems to be a reason for premature coronary artery disease.
The family history of premature CHD is a strong predictor for future acute coronary
event. Positive family history makes the young people more predisposed to CHD as
it is seen that these subjects show more plaque deposition leading to early
atherosclerosis. The premature CHD in these subjects manifests in form of severe
obstruction in coronary vessels (Otaki et al., 2013).

1.2.2 Modifiable risk factors

The modifiable risk factors are the risk factors, which can be changed with
diet and lifestyle intervention. The modifiable risk factors of CHD are discussed
below.

1.2.2.i Obesity
The accumulation of excessive fat is called obesity. Basically, an energy
imbalance, the etiology of obesity ranges from excessive food intake, sedentarism,
insufficient sleep and insufficient activity to genetic reasons. The obesity of both
types, the general obesity having a high weight in terms of height and the abdominal
obesity having high visceral fat are harmful.

Misra (2015) suggested a lower range of body mass index (BMI) as marker
of obesity for Asian population starting from 23 kg/m2, while for rest of the world it
is 25 kg/m2. Similar risk factors of CHD are observed in Asian population at lower

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BMI levels. The obese people tend to be less physically active and sedentarism in
itself is a risk factor of obesity. The behaviour modification along with diet and
exercise are recommended for control of obesity.

1.2.2.ii Dyslipidemia
Dyslipidemia manifests as increase in triglycerides and low density
lipoprotein cholesterol (LDL-c) levels or both and a decrease in high density
lipoprotein cholesterol (HDL-c) level. The role of cholesterol in atherosclerosis is
evident when at the site of endothelial injury attracts the LDL-c and apolipoprotein-
A [Lp(a)]to enter the sub endothelial space. The oxidized modified free radicals
present at these sites, enter the macrophages leading to development of the fatty
streaks and inflammation. The lesions thus produced grow through smooth muscle
cell proliferation and collagen production at site. If LDL-c level at this state is
elevated, the necrosis of foam cells occurs, causing an extracellular lipid core
formation. This accumulation generates an inflammatory response where
lymphocytes infiltrate the outermost connective tissue, the adventia, which cover the
vessel (Sima et al., 2018). This auto immune response is the real culprit behind the
formation and accumulation of plaque.

1.2.2.iii Diabetes
The condition of having blood sugar levels above normal is linked to CHD
as a risk factor. The hyperglycemia causes damage to the blood vessels that forms
the basis of atherosclerosis. Not only the presence of diabetes increases the risk of
CHD, it also causes the beginning of atherosclerosis before time, thereby, becomes a
major reason for CHD at early age. Diabetes accelerates atherosclerosis through
dyslipidemia, which is caused by disturbance in energy metabolism among patients
(Schofield et al., 2016).

1.2.2.iv Hypertension
Blood pressure is the function of cardiac flow effect on the walls of vessels
carrying blood. Narrowing of the blood vessels, due to atherosclerosis illustrates the

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rise in the blood pressure. The increased pressure that put strain on the cells of
myocardium, supplements the risk of atherosclerosis and thus CHD (Fuchs, 2020).

The highest prevailing and a strong risk factor for CHD among males is
Hypertension. It acts at the level of the blood vessels, wherever, damage is caused to
the vessel and if untreated leads to organ damage. The hypertension initially alters
structures and function of heart asymptomatically and then through subclinical
abnormalities at cellular level, causing gross manifestations like, left ventricular
remodelling, thus, increasing its wall thickness (Lawler et al., 2014).

It is the most undetected or undertreated risk factor contributing to a very

serious CHD event. Over one-third adults having hypertension in America were
reported to be undertreated or undetected (O’Donnell et al., 2010). The young
people remain unaware of the hypertension because blood vessels compensate the
pressure by adjusting the laminal flow. This is the main reason for asymptomatic
hypertension at young age (Ambrose & Najafi, 2018).

1.2.2.v Unhealthy diet

The unhealthy diet refers to the diet that is poor in quality in terms of
excessive fat in the diet, less consumption of fruits and vegetables, high in calories,
high in sugar or salt, consumption of transfats, frequently eating outside, binge
eating, etc. The traditional Indian methods of food preparation indicate high use of
saturated fats, transfats, overcooking, and excess use of salt and sugar. Indian’s
preference for ready to eat, processed foods, bakery products rich in transfat and
sodium has put Indians on high risk for CHD. Green et al. (2016) reviewed Indian
dietary patterns characterised by consumption of high sweet products and snacks,
which are harmful as they are high in energy, fat and contain transfats. The
vegetarian pattern was found to be still prevalent among Indians but use of dairy,
meat and eggs has increased. Further, they concluded that the unhealthy eating
habits, fasting and feasting habits of Indians multiply the risk of CHD.

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1.2.2.vi Tobacco smoking

Tobacco is consumed in many ways by people viz. smoking cigarettes, e-
cigarette vaping, chewing tobacco products, beedis, and passive smoking. Among
many chemical compounds found in tobacco, nicotene is the most studied
compound. The smoke induced production of free radicals become reason for
endothelial injury that adversely affects vasodilation functions and increase in
stiffness and lesions in intima. These pathological changes and the mechanisms of
tobacco use giving way to atherosclerosis have been discussed (Messner &Bernhard,
2014). As per Kenneth (2018) most preventable risk factor for CHD is reduction in
smoking. The risk reduction starts from the moment of quitting and by 15 years of
quitting the risk becomes equal to that of a non-smoker.

1.2.2.vii Harmful use of alcohol

The immediate effect of alcohol on blood pressure levels is observed in
many studies. Earlier moderate consumption of alcohol especially wine was thought
to be due to presence of the polyphenols. But recently, Leong et al. (2014)
demonstrated that in men from South Asia including India have shown no cardio-
protective benefit of moderate consumption. The practice related to binge drinking
and overconsumption on holidays or weekends have found to be harmful for heart
health (White et al., 2018).

1.2.2.viii Lack of physical activity

The other risk factor for coronary heart disease is insufficient physical
activity, which is the most common behavioural problem seen in CHD patients. The
commonly seen reasons behind physically inactive behaviour are insufficient
participation in leisure time activities like, sports, lack of exercise routine, sedentary
lifestyle, sedentary occupational activity, less physical involvement in household
work and increased use of technological advances for domestic work and transport.
The increase in screen time is also adding up in the sedentary lifestyle and also
linked to faulty food habits. Mandsagar et al. (2018) in their study discussed the role
of exercise in cardiorespiratory fitness and reported that the exercise reduces the risk
of CVD mortality. The role of physical activity in stress management is also

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pragmatic. The cholesterol lowering effect of exercise has also been demonstrated
(Mann et al., 2014).

1.2.2.ix Psychological stress

Physical, mental or emotional response of an individual towards the stimulus
from environment is the cause of stress. The stress induced depression and physical
inactivity are commonly seen in the CHD patients. Win et al. (2011) also reported
depression and physical inactivity to increase the risk of CHD.

Stress related depression alters many behavioural mechanisms in subjects

leading to poor adherence to dietary and exercise regime. The biological mechanism
through which stress elevates the risk of CHD is through its effect on autonomic
nervous system causing Arrythmias. These arrhythmias are then followed by
inflammation of endothelia, which becomes the cause of atherosclerosis making
stress an independent risk factor of CHD. The symptoms of stress from general to
specific could be irritable mood, feeling sad, emptiness, diminished interest or
displeasure in day-to-day activities, insomnia, restlessness, fatigue, lack of energy,
lack of concentration, indecisiveness, thought of death or suicide (Carney &
Freedland, 2016).

1.3 CONSEQUENCES OF CORONARY HEART DISEASE

The CHD, if left untreated leads to many grave problems in future. It
confirms its consequence on the cardiac blood vessels, valves, as well as, on the
heart muscle. The heart strives to compensate the ill effects of CHD by beating up
fast, building up additional muscle or extending to accommodate more amount of
blood. These compensations impinge on the heart’s functions and over the time
result in various consequences as discussed below.

1.3.1 Angina pectoris

When the flow of oxygenated blood to heart is reduced, due to narrowing of
the coronary arteries (supplying blood to the heart), the oxygen and other nutrients
supply to the heart muscle falls short. The shortage of oxygen to the heart causes
pain called angina pectoris (Muller-Nordhorn &Willich, 2017). Commonly mistaken

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for the heartburn, the feeling of tightness, pressure, heaviness, discomfort, shortness
of breath or pain is felt in the chest. Sometimes similar symptoms show up in left
arm, back, neck or jaws, which are due to angina pectoris.

1.3.2 Arrhythmia
The inadequate supply of nutrients and oxygenated blood or the damage of
heart muscle impede the electrical pulse generated in the heart leading to unjustified
variation of heart rhythm, called cardiac arrhythmias (Antzelevitch &Burashnikov,
2011).

1.3.3 Myocardial infarction

The acute event that occurs due to blockage in heart is called heart attack in
common language. The atherosclerotic build up is the most common reason for
these deposits on the inner walls of the blood vessels, which supply blood for the
functioning of heart. When the atherosclerotic plaque ruptures causing blood
clotting at the site, it blocks the artery of the heart. The origin of heart attack is
atherosclerosis in the blood vessels. The heart attacks are usually more disastrous in
the presence of the combination of risk factors such as, use of tobacco and alcohol,
unhealthy diet, obesity, physical inactivity, hypertension, diabetes and
hyperlipidemia. Lu et al. (2015) listed the symptoms of myocardial infarction
including chest pain, shortness of breath, nausea, sweating, abnormalities of
heartbeat and anxiety. The treatment involves taking asprin, blood thinners,
anticoagulants, oxygen and painkillers. Most of the heart attacks according to
Inamdar and Inamdar (2016) are caused due to CHD, inflammation in heart, high
blood pressure levels, cardiomyopathies and arrhythmias.

Strokes are also caused by bleeding from a blood vessel and clots causing
blockage in the brain. These blood clots can arise in any other part of the body.

1.3.4 Heart failure

The chronic deprivation of oxygen and nutrient rich blood to the heart
muscle makes it lose its capacity to pump blood towards the body. The lack of blood
supply damages the heart muscle permanently leading to heart failure. It doesn’t

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mean that the heart has stopped its function; it means that heart is severely impaired
and requires medical care. The congestive heart failure develops in two ways: acute
when the damage occurs suddenly and chronic when heart becomes weak gradually.
The mechanisms for cause of the heart failure are ventricular remodelling,
proliferation of the extracellular matrix, apoptosis, increased hemodynamic load and
abnormal calcium cycle (Inamdar & Inamdar, 2016).

1.4 PREVENTION OF CORONARY HEART DISEASE

The Framingham Heart Study (FHS, 2013; Mahmood et al., 2014) was
pioneer study to establish coronary heart disease risk factors and titled them as
‘Factors of Risk’. It was for the first time healthy volunteers were studied for the
presence of risk factors of CHD. Many researches after this study worked to
establish risk factors of CHD. The knowledge gained from the study of the risk
factors has laid the foundation of prevention approaches for CHD.

Reddy (2013) concluded that CHD among all atherosclerotic vascular

diseases is multi-factorial in origin. These risk factors operate continuously and may
occur simultaneously. The co-existence of many risk factors substantially increases
the risk of CHD exponentially. Most of the CHD events are resultant of the modest
elevations of multiple risk factors. According to INTERHEART& INTERSTROKE
studies standard risk factors, which are associated with 90 per cent CVD are high
Lipoprotein-B [Lp(b)], low Lp(a), high blood pressure, diabetes, high waist to hip
ratio(WHR), smoking/tobacco use, sedentary lifestyle, psychosocial stress, poor
quality diet and alcohol. Punjab has been reported to have high prevalence of these
risk factors and controlling these factors can prevent CHD among people
(O’Donnell et al., 2010).

Chrysant (2011) presented a concise review on the ‘cardiovascular disease

continuum’. He defined the cluster of risk factors like diabetes, dyslipidemia,
smoking, obesity, hypertension, etc. as the beginning of CVD. If the risk factors
progression is not intervened from the very beginning they progress to cause
atherosclerosis, which leads to CHD. The complexities show up as myocardial
infarction, ventricular dilation, and ventricular dysfunction and eventually end in

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heart failure or death. He provided evidence for the control of risk factors during
2000-2009 then concluded that early intervention or treatment for risk factors
prevented occurrence of CVD. Thus, early detection and control is pivot in
prevention of CHD. Early treatment for the uncontrolled risk factors to snub their
progression to severe disease through education based strategies has potential to
save organ damage. Non-pharmacologic means of changes based on weight loss, salt
restriction and exercise as interventions should be tried foremost for the reason that
they are serviceable. The reason for aggressive control of risk factors like,
hypertension is imperative initially because these risk-factors are really
uncomplicated at earlier stages. The early lifestyle and diet changes also save the
patient from developing complications secondary to pharmacological solutions. The
treatments using, diuretics, although show effectiveness in the form of lowering
blood pressure, is not a good option for hypertensive subjects having diabetes or
metabolic syndrome, because the diuretics increase blood glucose, which is related
to high incidence of CHD. Thus, the control of risk factors with diet and lifestyle is
really an effective strategy in prevention of CHD. Because atherosclerosis starts in
youth and is related to dyslipidemia, smoking, higher blood pressure, glucose levels
and body mass index, the implication is that prevention must start early in life.

The prevention is suggested at three levels: primordial, primary and

secondary.

The concept of ‘primordial prevention’ as per Gillman (2015) goes beyond

the concept of ‘primary prevention’. It denotes all the interventional activities to
prevent or stop the appearance of the risk factors into the population. As the
atherosclerotic changes start early in life the ‘primordial intervention’ must also start
early in life. It works on all types of exposures, which increase susceptibility of an
individual. ‘Primary prevention’ refers to measures applicable to a particular disease
or a group of diseases to intercept the cause of disease before they involve in man.
The risk reduction to prevent onset of the specific disease is crux of the concept of
primary prevention. It is a mix of alteration of individual behaviour and limiting
exposures to risk factors of the disease. Addressing the risk factors and enhancing
the individual’s capacity to resist the disease is the main strategy to reduce incidence

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of disease. The ‘secondary prevention’ is the medical treatment taken to delay the
next event when the disease has already developed. It is given to the patients who
already have undergone heart attack or stroke (Gupta & Wood, 2019).

1.4.1 Intervention for prevention of CHD

Rose Paradox explains that it is impossible to prevent the prevalence of
disease without targeting the knowledge and prevention strategies towards moderate
to low risk population. Providing health education to low to moderate risk
population can prevent their movement to highrisk category and then to the diseased
category (Thompson, 2016)

1.4.1.i Diet and lifestyle intervention

Dahiya et al. (2020) studied the risk factor awareness level and readiness to
adopt lifestyle related changes among the family members attending patients
undergoing treatment for myocardial Infarction. They reported that the level of
awareness of the risk factors was low amongst the family members. They also
observed a reluctance to adopt change in the lifestyle, despite witnessing a close
family member suffering from CHD. They concluded that an event happening to a
loved one might not be an eye opener enough for a family member. They suggested
an active effort on part of physician to educate the patient and his family members
about risk factors of CHD and its preventive measures. Further, they said that a team
based effort of physician, preventive team, and community workers should work to
identify and communicate the need for risk factor control, to stop progression of
CHD at early stages.

Ambrose and Najafi (2018) while proposing preventive strategies for

coronary heart disease emphasised on early detection. They also described healthy
diet/ lifestyle as backbone of any preventive strategy for CHD. The early diagnosis
of hypertension could be a preventive approach for consequent cardiac events. They
suggested screening at early age for hypertension, health education for consequences
of the disease, self monitoring and self care as the preventive approach to decrease
the burden of disease and associated risk factors.

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Devries et al. (2017) emphasized the importance of nutrition education by

quoting that nutritional work is actually interventional cardiology. According to him
nutrition has not been utilized fully and frequently to control CHD, which is a
simple goal to achieve. He also remarked on lack of nutrition education in
physicians, as well. In a study involving 930 surveys on cardiologists, physicians
and medical students, he reported that 90 per cent of the cardiologists never received
any nutrition education during their training or fellowship. Only 20 per cent of the
cardiologists adopted nutrition related healthy behaviour of consuming 5 or more
servings of fruits and vegetables per day. He admitted that imparting nutritional
knowledge to the patients is the most difficult step in nutrition intervention. Thus, it
is a nutrition educator’s job to design better programme for effective spread of
nutritional knowledge and lifestyle modifications.

Reddy (2013) suggested that cardio protective diet, based on principles of

CHD, should be an integral part of nutrition lifestyle counselling for prevention and
treatment of the disease. He proposed inclusion of fruits and vegetables (400 to 600
grams per day), small quantity of nuts, fish (2-3 times in a week), 75 per cent of fat
intake from PUFA/MUFA, less than 25% of daily fat intake having saturated fatty
acids, less than 5 g of salt per day and restricted use of sugar. He also emphasized
the importance of economic, cultural and local availability factors to be considered
while making dietary suggestions.

Joshi et al. (2007) compared risk factors responsible for early myocardial
infarction in individuals of other countries with counterparts in South Asia including
Indians. They identified eight common risk factors causing myocardial infarction in
more than 90 per cent of cases. These risk factors were dyslipidaemia, tobacco
use/smoking, hypertension, diabetes, obesity (abdominal), physical inactivity, low
intake of vegetables and fruits and psychosocial stress. They concluded presence of
higher level of the risk factors at a younger age as the main reason for early acute
myocardial infarction in the South Asian population and emphasized on lifestyle
changes early in life as a potential strategy to reduce risk in South Asian population.

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Tamrakar et al. (2014) discovered the fact that most of the young people in
which early onset phenomenon is observed were affected with single vessel (blood
vessel) disease. To be precise, 53.85 per cent of people who showed presence of
premature coronary artery disease (CAD) had blockage or damage in one main
blood vessel, supplying the blood to the heart. Such subjects are more disposed to
sudden cardiac event due to CHD or IHD. Only 36.9 per cent of the early on setters
had double blood vessel involvement for the disease manifestation, 6.1 per cent had
involvement of three blood vessels and 7.6 per cent had non-critical disease. This
means that for prevention of CHD, nutrition and lifestyle intervention should be
started very early in life.

1.4.1.ii Intervention for increasing knowledge about the modifiable risk factors
Khadka (2012) highlighted striking lack in knowledge about modifiable risk
factors in adults, residing in Kathmandu city, Nepal. He suggested that for
successful implementation of primordial, primary and secondary prevention of
CHD, the possession of knowledge is the basic requisition. As prevention is the key
strategy for any nation having very limited resources to combat any epidemic so, to
combat CHD, the knowledge of its risk factors among population and its prevention
approaches is pivotal.

Karmakar et al. (2018) reported low levels of knowledge behind the low
awareness levels, treatment and control of hypertension among people residing in
both, urban and rural India. They studied the control of hypertension among 651
patients, receiving pharmacological treatment, and found that only 48.2 per cent
were aware of their hypertensive condition, 47.1 per cent subjects continued
treatment, and only 8.8 per cent were able to maintain normal levels of blood
pressure. He suggested that the only way to prevent hypertension, being a colossal
problem in India, is its early detection, as hypertension is underlying cause of major
non communicable diseases. Improper understanding and lack of correct information
is linked to poor control over blood pressure in urban environment. The awareness
of hypertension was significantly associated to the participant’s age, education level
and socioeconomic status. They emphasized on need for imparting knowledge and
counselling for patients receiving treatment.

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1.5 SIGNIFICANCE OF THE STUDY

WHO (2014) revealed that out of 5.87 million deaths globally, 2.1 million
occurred in India alone, due to non communicable diseases. Among these 2.1
million deaths due to NCDs in India, 1.2 million deaths were of Indian men thus
indicating that men are more at risk. The fatality rates are reported to be high in
India, the major reason behind this being early occurrence, late diagnosis,
uncontrolled risk factors and lack of awareness among people. The life lost due to
premature mortality, due to CHD is found to be higher among men, this means the
loss in productive years causing great loss to family as well as nation.

Estrogen in women protects from heart disease by increasing HDL-c and

decreasing LDL-c, so pre menopausal women below age 40 years do not show
conventional risk factors (Bajaj et al., 2016).

Key indicators on Indian scenario (MCCD, 2018) suggest that the deaths
from disease of circulatory system increased from 24.3 per cent in year 2000 to 32.9
per cent in year 2018. Among all states, Punjab leads with 29.1 per cent of these
deaths occur here. Males were prone to prematurely die due to these as 61 per cent
male deaths occurred in productive years of life (35-69 years), of which 21.1 per
cent (25-34 years),29.1 per cent (35-44 years) and 36.4 percent (45-54 years)
indicating young males to be at grave risk. Any prevention based study must look
for risk factor occurrence before the males enter the age of risk i.e., 45 years.

In most of patients the prevention and treatment of CHD starts at the point of
diagnosis of disease, the diagnosis of CHD in young patients is difficult because
angiographic results of young coronary artery disease (CAD) patients showed
normal coronary vessels or very mild luminal irregularities, it may be due to natural
vessel wall compensation done by body to attain unrestricted blood flow but if they
suffer from CHD and the cardiac event at a younger age is more fatal (Aggarwal et
al., 2016) , thus it is necessary to observe and study risk factors of CHD at a young
age.

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 Introduction

Chrysant (2011) defined the cluster of risk factors like diabetes, dyslipidemia,
smoking, obesity, hypertension, etc. as the beginning of CVD. If the risk factors
progression is not intervened from the very beginning they progress to cause
atherosclerosis, which leads to CHD. The complexities show up as myocardial
infarction, ventricular dilation, and ventricular dysfunction and eventually end in
heart failure or death. Thus, early detection and control of risk factors of CHD is
pivot in prevention of CHD. Early treatment for the uncontrolled risk factors to snub
their progression to severe disease through education based strategies has potential
to save organ damage. Gillman (2015) goes beyond the concept of ‘primary
prevention’. It denotes all the interventional activities to prevent or stop the
appearance of the risk factors into the population. As the atherosclerotic changes
start early in life the ‘primordial intervention’ must also star early in life. It works on
all type of exposures, which increase susceptibility of an individual.

There are regional variations in the prevalence of CHD and its riskfactors
(Meshram et al., 2016). The dietary habits and food consumption also varies
regionally. Mitra et al. (2017) reported high prevalence of risk factors of CHD in
Amritsar, Punjab hypertension (33.2 per cent) and obesity (53.43 per cent), the
prevalence increased with age and peaked at the age of 50-59 years. CHD is largely
preventable thus efforts to control its risk factors must be done to save mankind
from havoc of CHD. Thus, prevention suggested should focus on the region specific
approach for the Indian population. This study will be beneficial for planning
prevention approaches more applicable on Indian population. Many Indian studies
have reported significant deficit in the awareness and control of risk factors of CHD.
Hypertension awareness ranges from 20 to 60per cent and is lowest in rural women
and highest in urban men. There are significant gaps in knowledge of epidemiology
of CVD and associated risk factors. In India regional variation in cardiovascular risk
factors such as smoking, obesity, hypertension, diabetes and lipid abnormalities
have not been systematically studied. Many studies have been conducted as an
attempt to quantify smoking and tobacco use. The other risk factors too, have yet to
be studied further to get proper viewpoint to design prevention strategies, specific

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 Introduction

for Indian population. The need to study prevalence at various sites and various
cities to get regional trends for future policy making is felt. The risk factor
awareness is essential to curb menace of CHD in Indians (Sekhri et al., 2014).

Moreover, the Indian population’s vulnerability to CHD is perhaps related to

modifiable environment, nutrition and lifestyle related factors. Studying the young
male population for identification and conveying scientific knowledge about
prevention to those at risk is the need of hour in prevention of CHD. The
conventional risk factors hypertension, dyslipidemia, obesity, smoking, diabetes,
physical activity will always be important in preventive approaches because the diet
and lifestyle changes are non invasive and have least side effects, can be encouraged
in mass population and can be beneficial in improving overall quality of life.

Muktsar city is an urban area of district Sri Muktsar Sahib of Punjab, India.
It is a historical town earlier known as ‘Khidrane ki dhab’; located in Malwa region
of Punjab. The district is a major supplier of snuff (a tobacco product) across India.
As per NFHS-5 (2021), district Muktsar has highest consumption of tobacco
products (20.8 per cent) and alcohol consumption (32 per cent) among all the
districts of Punjab, in men aged above 15 years of age. A high prevalence of
hypertension in district Sri Muktsar Sahib more than 46 per cent in men above age
of 15 years is also reported. This report highlights there is a dire need for such
studies in this area.

This study will help to increase the knowledge base for the CHD in Punjab.
There is dearth of knowledge in terms of diet and lifestyle, especially among Punjabi
population who have highest mortality rate due to CHD.

In the present study an effort was made to identify risk factors of CHD, their
prevalence and level of knowledge about these risk factors among people residing in
Muktsar city, Punjab. Further, an effort was made to assess the impact of nutrition
and lifestyle education intervention program on risk factors of CHD among subjects.

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 Introduction

1.6 OBJECTIVES OF THE STUDY

1. To study prevalence of risk factors of coronary heart disease among adult
males residing in Muktsar city, Punjab.
2. To find out the knowledge about coronary heart diseases of the people
residing in urban areas of Muktsar city.
3. To design and implement diet and lifestyle intervention program in selected
population.
4. To evaluate impact of diet and lifestyle intervention program on risk factors
of coronary heart disease in selected subjects.

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