Why Do the Poor Get Heart Attacks?
Lack of healthy lifestyle choices compound over time and affect the underprivileged more adversely
Contrary to popular belief, heart attacks are not confined to the affluent, who have the riches to revel in indulgent lifestyles. Indeed, in many high- and middle-income countries it is the poor who have heart attacks more frequently than the rich. In India, heart attacks have become more common among the impoverished and less-educated in recent years.
The main reason for this phenomenon is that the risk factors of heart disease have become more common among the poor, as social change tends to accompany economic development in evolving societies. Global experience vividly demonstrates these health and nutrition transitions. Initially, the epidemic of coronary disease, which causes a spate of heart attacks, manifested most prominently in the wealthier sections of high-income countries. But, over time, it evolved into a major threat to the poor among countries and the poor within countries. This followed changes over a period in the pattern of risk factor exposures in different population groups.
Most of the risk factors of heart attack are related to external elements that alter our physiology. Tobacco and diet are prime examples—even the levels of physical activity and stress are influenced by our environment. As societies develop economically, the social gradient of risk factor exposure reverses with time, with the rich purchasing protection and the poor becoming increasingly vulnerable.
Over a century ago, smoking tobacco was confined mainly to the more affluent, who had the means to spend on this relatively new affectation. Fat- and meat-rich diets and desserts were again a privilege of the monied. Motorized transport and labour-saving domestic devices, which reduce physical activity, could only be afforded by the upper classes. They were thus more likely to have heart attacks.
As the mediators of risk became mass-produced and marketed for mass consumption, the risk spread across all sections of society. Tobacco moved from fashionable clubs to street kiosks, becoming an aggressively marketed addiction for the poor. Unhealthy foods, from salt-rich snacks to sugary beverages, were commercially manufactured for sale to a wide range of consumers through multiple outlets. Manual labour decreased as public transport and home appliances became available to most. All social classes were now vulnerable.
Over time, the more wealthy and educated became aware of the risk factors of heart attacks and adopted healthier living habits to reduce their risk. Emerging scientific information on risk-enhancing and risk-reducing habits led to behavioural change in these sections of society who readily received and applied this knowledge.
Over the past 50 years, smoking rates fell among the rich even as it rose among the poor. The privileged adopted healthier diets, which the poor could not afford. Greater consumption of fruit and vegetables, choice of healthier cooking oils, reduced consumption of meat with increasing preference for fish—all of these changes accompanied greater health literacy among the more educated sections. The rich also pursued physical activities to keep fit in their leisure time, with the ability to afford gym memberships and play the genteel sports. Coronary heart disease rates came down first in the upper classes of high-income countries, even as they started going up among the lower-income groups.
Tobacco consumption is currently the highest among the poor and less educated, in all countries. Dietary diversity is low among the poor across the world who consume very small amounts of fresh fruit and vegetables, which protect against heart attacks. The poor are also compelled to consume foods cooked in unhealthy oils, which are less expensive but contain high levels of heart-attack-causing trans-fats. They derive energy mostly from refined carbohydrates in their diet, but their bodies pay a price by generating inflammatory chemicals and undesirable blood fat patterns. Stress levels are high due to the vicissitudes of their daily life while opportunities for pleasurable and safe physical activities are few.
Even as the poor have limited access to health information and means to better diets, health systems tend to neglect them with respect to timely detection and adequate treatment of early symptoms, such as high blood pressure and diabetes. Access to more expensive treatments and technologies is restricted and the poor are more likely to succumb to heart disease once they develop it.
Poverty even influences the way genes express themselves. Research conducted in many countries, including India, clearly shows that poor nutrition in the womb and during formative years increases the risk of heart attacks and diabetes in adulthood through induced ‘epigenetic’ (the way genes express themselves) changes in gene expression. Is it any wonder then that the hearts of the poor are paying the price for the mal-adapted modernity globally and growing income inequalities in the 21st century?
Dr K. Srinath Reddy is president, Public Health Foundation of India. He was awarded the Padma Bhushan in 2005.