Doctors wield enormous power over people’s lives because they have a monopoly on the knowledge of diseases and their appropriate treatment. Needless to say, such power must be exercised with great responsibility, particularly when on primetime television. But on several occasions, in the ill-considered debates around health that are watched by millions every night, prudence takes a backseat, and alarmist soundbites get preferential airplay. Things have come to a head with the discussions and pronouncements following the recent, unfortunate demise of a young actor (Puneeth Rajkumar). This time, one was inundated by anxious queries not only from laypersons, but also from some non-cardiologist physician colleagues: Am I at high risk of having a heart attack just because I am Indian? I have been exercising regularly; should I stop till I get a CT scan done? Many of these questions have clear answers that are based on good quality medical research. It may be worth addressing three of these, both in order to allay anxiety, and to set the record straight.
First, are you prone to having a heart attack just because you are an Indian? Researchers have known for some time now that South Asians (Indians, Pakistanis, Bangladeshis and Sri Lankans) with heart attacks are on the average five years younger than those with heart attacks from other parts of the world. This is often cited as evidence of a “genetic” predisposition, as if we are fated to suffer heart attacks at a young age just because we are Indian. However, there are two good explanations for this finding that have nothing to do with an inherent predisposition. The first has to do with population structure. We have a younger population compared to developed countries, and, therefore, given similar risks, there will necessarily be more young people with heart attacks, simply because there are more young people around. Second, Indians tend to be less physically active, and eat a less healthy diet, and are, therefore, prone to develop high blood pressure and diabetes, which are risk factors for developing heart disease. And sure enough, researchers have found that the risk of having a heart attack among South Asians is just as well explained by the distribution of these common risk factors, as it is in other populations. So, the principles of preventing heart disease are the same wherever you are from. Broadly, this means eating lots of fruit and vegetables, exercising regularly, and not smoking. You don’t have to be worried about being Indian!
Should every Indian male over the age of 40 get tested for heart disease? This question was apparently provoked by the public admonishment of all Indian males over the age of 40 years for exercising before they had had an electrocardiogram, an echocardiogram, and a CT scan done; it did not matter if they were already running 10 (“or a 100”) miles a day. This is egregious misinformation masquerading as medical advice, and is dangerous at so many levels. First, routine CT scanning or echocardiography are not advised in individuals who do not have any symptoms on exertion. They do not prevent future heart attacks. And there are a number of risks of doing uncalled-for tests in this population (particularly a CT scan). The risks due to the procedure itself are non-trivial and cannot be brushed aside. But, more importantly, testing is likely to trigger a cascade of further, and more invasive testing and treatment, none of which is likely to be beneficial. The associated anxiety, not to mention the costs, are other reasons that scientific bodies do not recommend this approach. On a related note, people undergoing unindicated cardiac stress testing as part of “executive check-ups” face a similar predicament.
Second, if you have been exercising regularly without symptoms, you may continue to do so safely without the need for any additional testing. Third, if you are a sedentary male, but otherwise healthy, and wish to begin exercising, you may do so by adopting a sensible approach — start slowly and increase intensity gradually, under supervision. On the other hand, if you are diabetic, have high blood pressure, or have symptoms, then it would be prudent to consult your physician before beginning your exercise regimen. Even in such instances, testing may not be mandatory, and your physician may simply add medications to your exercise prescription.
The reason why testing does not help identify people who may suffer a heart attack during exercise is that this risk is so very small. Among males, the risk of this unfortunate event is about 1 in 15 lakh bouts of exercise. To put this in context, exercising five days a week, you would have performed only about 15,000 bouts of exercise over your entire lifetime. And this risk is lowest among people who exercise regularly.
How vigorously should you exercise? Here the mantra is moderation. Moderate intensity exercise provides the greatest benefit. For the large majority of people, moderate intensity exercise means brisk walking for anywhere between two-and-a-half to five hours a week. For younger and more active people, it may be jogging, or for some even running. Although there are more formal methods to determine exercise intensity, a rough guide to knowing if you are doing moderate intensity physical activity is the so called “talk test” — you should feel too winded to sing, but not so breathless that you cannot talk. Further increases in intensity are subject to diminishing returns in terms of health benefits. Unaccustomed heavy exertion may be harmful, particularly among people with risk factors for heart disease.
Finally, it is important to consider why we are repeatedly faced with these episodes of unnecessary mass anxiety; previous ones were centred on plasma therapy and remdesivir for Covid-19. Debates on primetime television have become the norm during this pandemic, but are far from ideal for health messaging. The limited time, and the wide variety of opinions voiced, often make for unclear or even conflicting messages. To complicate matters further, television anchors, for all their omniscience, cannot be expected to grasp the nuances of complex medical issues, and may not focus on the most pertinent issues. Television as a medium should, therefore, simply be used to convey the well-considered recommendations of a scientific body to the general population. Doctors, on their part, should refrain from making pronouncements on topics beyond their specific areas of expertise.
This column first appeared in the print edition on November 4, 2021 under the title ‘The TV studio clinic’. The writer is a professor of cardiology at the All India Institute of Medical Sciences, New Delhi. Views are personal.