Why is blood pressure killing South Asians?

In the 1990s, I was a practising family physician in Lahore. In a lecture, a foreign cardiologist gave us a limit of permissible blood pressure levels and told us that if you see anyone above these limits, consider it a medical emergency and send this person to the hospital. We looked at each other and smiled, as most of our patients’ resting blood pressures were above these limits.

A few years later, I was at the University of Washington, and I took a class on ‘cardiovascular epidemiology’. As a requirement, I had to write a review paper to get credit. These were the days when most medical references were still in published paper journals in medical libraries. You first needed to find references from a huge, multi-volume bibliography called ‘Index medicus’. Then we needed to find specific journals on long shelves and then take them to the photocopy machine to copy those references. It was a long manual process, so we always spent a good amount of time trying to filter the best references. While doing research on cardiovascular diseases in the South Asian population, I stumbled on two facts. The population of South Asians who have immigrated to developed countries increases its cardiovascular risk manifold. Second, their cardiovascular risk in their new countries is also manifold higher than that of the indigenous population of these countries. Most of this research was done in the 1960s and 1970s, and it was mind-boggling for me. My hypothesis was that, biologically, South Asians may be a bit different from others, and once their environment changes, they become more susceptible to heart diseases. It was a very different angle on a common disease, and my professor liked it. Using the same hypothesis for TB, later in US-CDC, I did a major research on TB among South Asians living in the US and found similar issues.

So why did they have lower cardiovascular risk in their home countries and it only increases once they immigrated to advanced countries? I believed that until the 1970s or even the 1980s, our lives in South Asia were still simple and free of pollution. The population density was 30% of what it is today. Our food habits were also simple. I remember telling my American classmates about our healthy snacks compared to their unhealthy snacks. Our fruit chatt was actually a fruit salad with tamarind and yoghurt vs a fruit salad in the US with a lot of artificial creams, mayonnaise and sugar. Another favourite snack of the 1990s was corn cooked in hot charcoal mixed with sand. Pizzas, mass-produced burgers and fries were not so common yet. Probably that is why we, as a susceptible group for heart diseases, had a lower risk in our countries, but once we moved to more advanced countries, our risk increased manifold.

Things have changed now. Our city populations have grown tremendously, not only due to a three-fold increase in population but also internal movement from villages to cities. Pollution has increased manifolds. Our food is now worse than in the West, as we have lost our natural meals, and mass-produced foods are favourites with no quality checks.

So, it is no surprise that heart diseases are topping the charts in Pakistan and India. Lack of reliable data on any diseases is a problem here. A relevant study estimates that there are more than 2 million new heart patients and more than 200,000 deaths every year in Pakistan. India has similar numbers in proportion to its size. We are also witnessing fatal heart diseases in the younger population.

Genetics, obesity, blood sugar and hypertension are the most common causes of heart disease in Pakistan and India. Continuously increased blood pressure makes our blood vessels less elastic, which then decreases blood flow to the heart, which helps start heart disease. We could easily decrease our blood pressure through regular exercise, salt reduction in our meals and avoiding prepackaged food. These measures will help you reduce your risk of diabetes and obesity too. But if the above steps are not giving you good results, then couple them with simple and basic antihypertensive and diabetic medicines as prescribed by your doctor. Remember, first you need to modify your lifestyle, and only then can medicines have the best impact.

Published in The Express Tribune, December 11^th, 2023.

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