A Passage to India: Establishing a Cardiac Rehabilitation program in India s south-east

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1 A Passage to India: Establishing a Cardiac Rehabilitation program in India s south-east Kathryn Kelly Clinical Nurse Consultant, Cardiac Rehabilitation Coordinator The Royal Melbourne Hospital

2 India 1,025,000,000 people 28% of population live in cities 300 million live below poverty line 35% of population live on <$1 US/day

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4 Facts about India Average life expectancy:64 yrs Only 5% of India s population is over 65 2% of central Govt expenditure allocated to health (2004) 2% of central Govt expenditure allocated to education (2004) 14% of children (5-14yrs) in child labour

5 India s Economy India s traditional image is overshadowed by strikingly new ones Today the country is known for call centres, software and pharmaceutical companies

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7 India s Economy (cont) Growth has averaged 8 per cent per annum since 2003; second only to China The country s young population means India has the potential to grow faster than China in the long term

8 Heart disease - the Indian context India is on the threshold of an epidemic of CVD CVD is now more prevalent in China and India than all economically developed countries in the world combined WHO 2003

9 Heart Disease - Indian context In India, it is estimated that 52% of the deaths occur among people under the age of 70, compared with 22% in the west.

10 Heart Disease - Indian context Many developing countries are still affected by the first wave of Heart Disease - of infective origin especially Rhematic Fever

11 Heart Disease - Indian context The 2nd wave of ischaemic heart disease is because of: life span and infant mortality in income leading to adoption of unhealthy eating habits and behaviours of western countries, and Urbanisation

12 Heart Disease - Indian context Rapid increase in the proportion of urban inhabitants (currently at 28%, with a projected rise to 43% in 2021) Current projections suggest that by 2020 India will have the largest CVD burden in the world (~60%) WHO 2003

13 Heart Disease - Indian context One fifth of the deaths in India are from CHD. By the year 2020, it will account for 1/3 of all deaths Heart disease in India occurs years earlier than in the west

14 Heart Disease - Indian context With increasing rates of urbanization in India, major changes in lifestyle patterns have occurred for a large proportion of individuals

15 Heart Disease - Indian context This has led to a trend towards physical activities due to improved transportation and availability of energy saving devices, increasing weight and consequently levels of diabetes, HT and dyslipidaemia in urban populations

16 Hyderabad - south east India Sixth largest city in India One of India s two main IT cities Hottest temperature recorded on the world s surface

17 Dr Prateek Bhatnahar

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22 Cardiac Rehabilitation venue Located in an office block approx 3 kms from two major referral hospitals Located above a motorbike sales shop It was a shell 21 days prior to official opening

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24 Cardiac Rehabilitation program Start two weeks after discharge from hospital Equivalent to $300AUD up front fee One try before you buy session offered Invitation open to patients after CAGs, AMI, PCI & UAP Spouse encouraged to attend

25 Cardiac Rehabilitation program Format Two hours a day 8am - 10am or 11am - 1pm Three times a week Mon, Wed, Fri or Tues, Thurs, Sat Four week duration

26 Education session - Topics Normal heart function. Stable and Unstable Angina, AMI. Tests and treatment options for heart disease Diabetes Heart Disease - how big is the problem?. Doing CPR at home

27 Education session - Topics Risk Factors (a) Age, + Family History, Gender, Smoking and Cholesterol Risk Factors (b) BP, Cholesterol, Inactivity, Diabetes, Depression, Stress

28 Education session - Topics Emotional impact of heart disease Exercise and activity > cardiac event Healthy shopping and cooking techniques

29 Education session - Topics Fats, and Cholesterol - Recipe Modification Cardiac surgery Stress management. Relaxation Techniques

30 Equipment 4 exercise bikes 1 stepper hand weights 2 sets of stairs 30 stackable chairs Tea and coffee facilities

31 Exercise component Moderate intensity group exercise session 45 minute duration Warm up, seven circuits, cool down

32 Types of Cardiac Surgery in India Ten years ago 50% valve surgery 30% congenital 20% IHD Now: 70% IHD 30% congenital 20% valve surgery

33 Cardiac Surgery in Hyderabad Available to middle and upper class $2000 for cardiac surgery package Hospital stay 7 days 1 or 2 days pre-op 4 of those days in ICU with 1:1 staff:patient ratio Day 5 7: cardiac ward with 1:40 ratio

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47 Dietary issues in India The paradox is that poverty abounds in a time of plenty -Stark contrast between malnutrition and over nutrition

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51 Dietary issues in India Indian trends: abdominal weight gain, elevated levels of LDL cholesterol &triglycerides, deficiency of HDL

52 Dietary issues in India Aim: waist circumference: Europeans: males 94cm females 80cm Asians: males 90cm females 80cm One in five teenagers in Delhi are obese, a gov t report showed that one in three children under three are clinically underweight

53 Dietary issues in India Indians consume large quantities of CHOs (such as rice and bread), ghee and fried foods and processed foods (many of which are high in trans fatty acids)

54 Dietary issues in India Moreover, the vegetables that are consumed are often overcooked (diminishes the potentially protective micronutrients compared with raw or properly cooked vegetables)

55 Dietary issues in India Ghee - a solid animal fat - traditional flavour - used almost exclusively for cooking in India

56 Diabetes Asians have the highest incidence of diabetes 2-3 times that in western countries. Status symbol upper class - overweight

57 In India, where we all know that there is a malnourished population, there are also now 35 million diabetics, and they are, for the most part, as the direct result of being overweight. Diabetes (cont)

58 86% of all cardiac patients in Andhra Pradesh have Diabetes highest rate in India, and one of the highest in the world Diabetes (cont)

59 Smoking 56% of Indian males aged years smoke Chewing tobacco: 7% of children use beedies or paan smokeless tobacco

60 Policy efforts Currently public health programs and health systems have been designed to address primarily communicable diseases and conditions affecting maternal and child health

61 More attention to prevention and control of chronic diseases have not been integrated adequately by these public programs Policy efforts

62 Development of programs to promote healthy dietary patterns and physical activity in schools and workplaces Policy efforts

63 Aggressive screening for, and modification of, traditional Risk Factors in south Asians at an early age would substantially reduce the high rates of early onset CHD in this population Policy efforts

64 Policy efforts required to: Reduce CHO intake to reduce rates of abdominal obesity and dyslipidaemia Reduce sodium content of packaged foods to lower the rate of HT and Increase regular consumption of fresh fruit & vegetables, to lower CHD risk Policy efforts

65 Engage leaders of the community to encourage leisure time physical activity among urban men and women Policy efforts

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