When human beings were hunter gatherers, the diseases they contracted were zoonoses – diseases spread through animals. When man turned to agriculture, he settled in the river banks and his clan stayed together. Then the most common diseases were infections. Later, as the industrial revolution was followed by digital revolution, a new set of illnesses came into being – the Life Style Diseases or as generally put, non-communicable diseases. Currently in the world, approximately 50% of death is due to non-communicable diseases (NCD).
They include cardiovascular diseases (CVD), diabetes, accidents, mental, disorders and chronic lung diseases. In India also nearly half of death is due to NCD and CVD is the most common component causing death. Currently it accounts for 35% of all deaths in India and is increasing along with its not so friendly neighbor, China.
The modifiable risk factors for CVD include, high blood pressure, dyslipidemia (abnormality of Cholesterol), diabetes mellitus, over weight and obesity and smoking. The other lesser factors are sedentary habit, mental stress and dietary habits. Primary prevention of CVD in an adult is by controlling the above factors. One can possibly prevent the CVD risk factors by primordial prevention, which is theoretically appealing but less practical.
The final common pathway of CVD is atherosclerosis which is a deposition of fatty and other material in the wall of arteries supplying the heart, brain, kidneys etc. Many studies done in young people who die young – during the wars, accidents etc, have shown that atherosclerosis begins in the adolescence and accelerates in the adult. The adolescents share the same CVD risk factors that of an adult population.Hence, prevention of CVD could start from adolescence.
In our state, these major CVD risk factors are high in prevalence. Nearly 10% of adult population have coronary heart disease, at least 30% of adults have high blood pressure, 10-15% of adults have diabetes and 20-30% of men still smoke. In addition, the average value of cholesterol in the blood of Keralites is higher than the optimal values. Over weight and obesity prevalence is increasing.
Many studies in Kerala have shown that high blood pressure is seen in children at least in 5%, obesity in 5% and insulin resistance to be more in children of Kerala. In the young adults of Kerala, the prevalence of all CVD risk factors are above the national averages. And most importantly, all these CVD risk factors track to adulthood.
These phenomena convey a crucial message. If we could start controlling the CVD risk factors from adolescence onwards, that would lead to reduction in the burden of CVD risk factors in the young. That would translate into reduction of CVD risk factors in the young adult and further cause reduction in CVD in the adult. This is the fundamental basis of preventive cardiology in the young. One has to ‘Catch Them Young’ and make young people “heartsmart”.
In the west, screening children and adolescents for high blood pressure, obesity and dyslipidemia is becoming popular. Some of the screening can be universal - high BP and obesity and some can be selective – for dyslipidemia. We in Kerala can also screen our adolescents for CVD risk factors, probably concentrating on high risk population.
The screening could be achieved either by universal screening or selective situations and offered preventive and remedial measures.
A Preventive Cardiology in The Young Clinic can offer a lot to at risk population of adolescents. At risk population include those children whose parents and/or grandparents having premature CAD, having high lipid values and those children who are hypertensive, smokers or obese.
The concept of a preventive cardiology in the young can be conceptualized as a multi-disciplinary team taking care of adolescent cardiovascular health. We have termed these proposed clinics as Adolescent Cardiovascular Health Clinics as we will stress on maintaining health rather than treating morbidity.These clinics also look at children who had Kawasaki disease in their early childhood, who were born lighter (Birth Weight <2.5 kg) or who have chronic kidney disease.
The three crucial components of care givers in AHCs are Pediatrician, Pediatric Cardiologist, Nutritionist and Pediatric endocrinologist. The clinic can also have additional input and support from physical medicine, obstetricians and nurses.
KIMS is planning to start a AHC program from January 2020 onwards. This is going to be a bi weekly focused clinic to be run by pediatric cardiologist, pediatric endocrinologist and nutritionist. The clinic will the first of its kind in private sector. Beginning from January, adolescents can be directed to the clinic by pediatricians, physicians, cardiologists, public health nurses and even teachers. The aim will be a multidisciplinary approach to modify adolescent CVD risk factors, involving the entire family.
Those who can visit our clinic
1. Overweight and obese adolescents
2. Adolescent with high blood pressure
3. Adolescents whose parent has a premature CVD
4. Adolescent who smokes
5. Adolescents who were either LBW or had Kawasaki disease in childhood.
In addition, our intention will be also to take care of adolescents who have a chronic cardiac illness – either congenital or acquired or post-operative congenital heart disease. They are generally ‘orphaned’ due to their age, both by pediatricians and physicians.
In conclusion, starting of a dedicated Adolescent Cardiac Health clinic is a great investment for the future. An investment which could reduce both individual and societal burden of CVD in our state and country.
Dr. Zulfikar Ahamed
Paediatric Cardiologist,
KIMS Hospital,
Trivandrum
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