Traditional approaches regarding healthy heart strategy have largely remained individual
centric with emphasis on educating individuals about conventional risk factors (smoking,
diabetes, hypertension, dyslipidaemia, physical inactivity) with an aim to modify
them. This strategy is based on the premise that cumulative effect of modifying these
risk factors in individuals will result in population based changes (in these risk
factors) leading to a decrease in the cardiovascular mortality of the population.
On the other hand, environmental approaches for the healthy heart recommend a paradigm
shift from individual centric approach to an upstream approach of changing the overall
environment of the individual, society and nation by involving societies, local bodies
and governments.
India being home of around 62 million coronary artery disease (CAD) patients with
a relatively younger population being affected1, such strategies are of paramount
importance. Ban on smoking in public places is an example of creating healthy heart
environment. To create heart healthy environment, we need to identify (i) individual
and population goals, (ii) high risk population, and (iii) barriers and promotors
for change. Motivating an individual to change the environment poses many barriers
and is unlikely to be effective2.
Creating environment for physical activity
Create built environments that make it easier for people to be physically active,
particularly by facilitating people to walk and cycle. Built environments include
buildings, grounds, layout of societies, roads, cycle tracks, parks, transportation,
etc. Societal changes in the modern societies, mechanization, and computerization
have put barriers to the physical activity leading to a dramatic decrease in the routine
physical work. Physical activity could be recreational/exercise, household, occupational
and transportation related. All these spheres have different built environment, regulations
and policies. Provision for parks and recreational activities for children, families
and institutes/organizations such as schools is an important factor for promoting
exercise. Easy accessibility to parks, sport fields and trails is positively associated
with physical activity. Quality of these facilities is also a significant contributor
to physical activity. Surrounding scenery, trail conditions, absence of noise, lighting,
rest rooms promote trail use while parks with walkways, courts and multipurpose facilities
are likely to promote physical activity3. Dedicated bicycle paths/trails may promote
active transportation. Presence of a public transport facility nearby and its use
are also associated with increased physical activity as solely walking to and fro
from public transport facility contributes to physical activity. A good public transport
system is important for active transportation and also contributes to less vehicular
pollution. Proximity of workplace/school to residence, supportive pedestrian infrastructure
and safety conditions are consistently associated with higher rates of walking. An
international study has shown that in activity supported residential areas walking
rates are two times higher than least supported neighbourhoods4. In nutshell, health
professionals should collaborate with the local governments to make it easy for people
to be physically active by changing the way that the built environment is designed.
Planning for a healthy built environment puts the needs of people and communities
at the heart of policy decisions regarding spaces in which people live, work and play5.
Food and nutrition
Obesity, hypertension, dyslipidaemia and lack of fruits and vegetables in the diet
are food-related risk factors for heart disease. A diet low in fat and sodium; moderate
in calories and protein; high in fruits and vegetables, fibre, potassium, antioxidants,
and other vitamins and minerals will help prevent atherosclerosis and hypertension.
Food environments include cultural, familial, institutional, and commercial policies
and practices for food production, acquisition, preparation, and consumption. Food
habits vary widely in our country but in general food is fried and sugar rich leading
to a higher incidence of diabetes and CAD. A ban on the sale of aerated cold drinks
in schools is one such example of preventing potentially unhealthy food to school
children. Design and layout of cities and towns is an important component in providing
people physical and affordable access to safe, adequate, nutritious and culturally
appropriate food. Governments and municipalities can play a key role in enabling food-sensitive
planning and urban design to be implemented, which includes identifying opportunities
for better access to healthy food for all. It will be appropriate to discourage the
promotion of fast foods, by setting examples in healthcare facilities and schools.
Air and noise pollution
Nearly 80 per cent of all premature deaths due to air pollution are because of cardiovascular
diseases. Fine particulate matter also called PM2.5, has the ability to reach lower
respiratory tract and thus enter the blood flow in large amounts with lots of toxins.
PM2.5 and NO2 originate from industrial and vehicular combustion and are associated
with increased incidence of severe heart attacks6. The impact is so much that the
cardiac patients are often advised to stay indoors during rush hours to avoid vehicular
pollution. World over, efforts are on to set norms and accountability for various
causes of air pollution and formulate ways and means to minimize. Use and promotion
of new and innovative technologies to decrease the industrial pollution is a matter
of discussion at many international fora7. Noise pollution also contributes to the
development of hypertension and atherosclerosis. Noise related stress is responsible
for disturbances in autonomic nervous system leading to hypertension and accelerated
atherosclerosis. A healthy heart strategy for air and noise pollution includes stricter
norms for vehicular and industrial pollution, public awareness about recognizing it
as CAD risk factor, no-honking zones, promotion of clean and green energy (solar energy)
and a wide range of other policy matters8.
Smoke and tobacco free environment
Cigarette smoking and tobacco are well established risk factors for atherosclerosis.
In recent years, health professionals have worked with governments and policy makers
to reduce the prevalence of smoking in the community. A sustained campaign against
tobacco products encompassing a wide range of social environmental conditions that
create opportunities for smoke-free living is required to create a smoke free environment.
Ban on smoking in public places, large warning signs, increase in taxes on tobacco
products and all together ban on certain tobacco products are some of the initiatives
that help in creating tobacco free environment. Consumption of tobacco which is causal
factor in one third of CAD population1 needs to be addressed more seriously by policy
makers and the peer groups to make it socially unacceptable.
Health and prevention
Preventive and medical services are important contributors in creating healthy heart
environment9. Affordable, accessible and convenient health services ensure better
prognosis of cardiac diseases. Management and modification of cardiac risk factors
such as hypertension, dyslipidaemia, and diabetes also prevent CAD. Screening programmes
for CAD risk factors identify at risk people, who would benefit from early counselling
and treatment. Primary health care workers (family physician, ASHA or multipurpose
health worker) play an important role in CAD prevention by treating risk factors.
Guidance in simple and appealing language could be provided to the general public
and primary health care workers on the importance of the most common risk factors
and the most effective interventions. An example is the “rule of 80”10 which has been
proposed in 2004 and has since been modified to incorporate new evidence (Table).
Along with primary health care facilities, speciality health care by cardiologists
and endocrinologists is also required to treat advanced and complicated cardiac diseases.
Adequacy of emergency health care system, early recognition of heart attack symptoms,
availability of ambulances, and unique phone numbers for emergency calls and training
for cardiopulmonary resuscitation are critical for saving many lives in the first
few hours after myocardial infarction. Coronary care units (CCU) have contributed
to significant reduction in the mortality due to myocardial infarction. Usually CCUs
are available in large tertiary care centres in large cities. Proper distribution
of tertiary hospitals and transportation services will ensure that the people living
in remote areas can also be transferred to speciality hospitals in minimum possible
time.
Table
Rule of 80 for coronary artery disease
A new problem that has cropped up because of rapid evolution of technology is overprescription
of investigations. This not only takes up significant time and resources but also
leads to over treatment when none or less is enough. A classic example is coronary
angiography which is an invasive diagnostic test that typically starts a therapeutic
cascade involving revascularization. A joint initiative from health care providers,
society and government can take care of this problem. One such example is the Society
for Less Investigative Medicine (SLIM)11.
There are many other socio-economic factors which also contribute to provide healthy
heart environment. Economic prosperity, employment, education, social support, public
and personal safety are also critical factors in promoting overall health including
healthy heart environment12. There is a need to generate momentum for creating environment
for healthy heart. Some of the latest initiatives by the government such as “Swachh
Bhaarat Abhiyaan” is one such step in this direction. We have a long way to go and
all spheres of life to contribute in creating environment for healthy heart.