New Delhi: A programme encouraging entire families to adopt a healthier lifestyle can reduce the risk of heart disease in families with a history of early coronary heart disease, found a new study of 750 families in Kerala.

A family history of early heart disease (diagnosed before 55 years) means a person has 1.5–7 times higher risk of future cardiovascular diseases, says the study, published in The Lancet in October 2021, and conducted from January 2015 to April 2017 in Kerala. For the study, health workers provided 368 families with regular check-ups every one-two months, and encouraged them to change their diet, exercise more and avoid tobacco and alcohol, while also connecting them to a primary health centre. These families were compared with 382 families who received 'usual care'--one-time counselling and an annual screening.

Researchers found that it was more effective to encourage the whole family to make lifestyle changes rather than usual care. This is because families work within the framework of biological and cultural relationships, and health-related behaviour, such as diet and exercise, is often difficult to change without the understanding and support of other family members, the study said. Family relationships also help to improve the health and wellbeing of family members struggling with the management of other chronic diseases, it added.

Cases of cardiovascular diseases in the world nearly doubled from 271 million in 1990 to 523 million in 2019, according to estimates from the Global Burden of Disease Study 2019. In 2019, over 2.5 million died in India from cardiovascular diseases, accounting for 13.5% of global deaths from heart diseases.

Indians are more prone to heart disease--the rate of heart disease in Indians is double the national average of the western world. It also typically occurs at least 10-12 years earlier in people of Indian heritage than in individuals who reside in high-income countries, the study said. Heart disease also leads to extreme financial distress, especially in low and middle-income countries, such as India.

A family-based approach is also important because the excess risk due to a family history of early heart disease is not just due to genetic factors, but "substantial evidence shows that it is due to shared environment, and similarity in behaviour and belief systems within families", the study said. The reduction in total cardiovascular risk after families adopt healthy behaviour has the potential to impart public health benefits and save productive life years in India.

The family-based model has been found to be successful in other South Asian countries too. A similar model--with home visits by trained government community health workers--had reduced blood pressure in more patients with hypertension than with usual care, found another study in Pakistan, Bangladesh and Sri Lanka, published in February 2020.

The intervention

Non-physician health workers, such as accredited social health activists (ASHAs) and trained nurses, made a median of 13 visits to each family over the course of two years, measured their blood pressure and blood glucose, and checked a regular health diary that families were asked to maintain. Health workers also encouraged families to increase locally available and seasonal fruits and vegetables in their diet to four-five servings per day, reduce salt intake to a quarter tablespoon per person per day, intake of sugar to less than two tablespoons a day and increase the duration of regular daily exercise (mostly walking) to 30-60 minutes. Healthcare workers asked families to abstain from tobacco products and alcohol.

Health workers were trained for 2.5 days to counsel families and in using devices to measure blood pressure and blood glucose. They received Rs 250 for each visit to the family to cover travel and other expenses.

Families were asked to visit the hospital once at the end of the first year and then at the end of the intervention to track their health. The researchers considered four main outcomes: blood pressure lower than 140/90 mm Hg (millimetres of mercury); fasting blood glucose less than 110 milligrams per decilitre (mg/dL); low-density lipoprotein--the level of cholesterol in the blood--less than 100 mg/dL; and abstinence from smoking or tobacco use. A family (barring the individual who had already been diagnosed with heart disease) should have maintained or achieved any three of these at all check-ups during the study.

"There are few studies in the literature which explore lifestyle changes in a family setting," said Dorairaj Prabhakaran, a cardiologist at the Public Health Foundation of India (PHFI), and one of the authors of the paper.

The results

At the end of the second year, 64% of 807 people who were part of the group that received family-based care had met three of the four outcomes. In addition, 74% had met the required level of blood pressure at the end of the second year. The authors also calculated the average estimated Framingham risk score, which are estimates of the level of risk of cardiovascular disease over 10 years. This had decreased from 11.4% to 8.1% in the family-based care group, compared to a reduction from 12.2 to 11.4% in the usual care group.

Further, the odds of achieving at least three of the outcomes was two times higher in the group that received family-based care versus those that received usual care, the study found.

Cardiovascular risk reduced in all who received family-based care, irrespective of factors such as sex or age, showing that changes targeting a family's adoption of healthier choices influence all family members equally, the study said.

The study does not include the 'Ripple effect' of the programme, which is the impact on people who were not directly involved in the study but might have been exposed to the intervention, such as children or immediate relatives of the family, the study said.

India's health and wellness centres could help programme scale-up

Though the study showed that family-based programmes to reduce the risk of heart diseases can be successful, the study was done in Kerala, in a population that is highly literate and had visited a hospital. Further, as the research was at a single healthcare centre, it included families from similar socioeconomic backgrounds, Prabhakaran explained. "The study was done in Kerala where health literacy is high and innovations are welcomed. Its application in states with poor literacy needs to be studied," said Prabhakaran.

The programme cost approximately Rs 3,500 ($47.4) per family. The programme also requires training of healthcare workers to conduct regular checks and advise families on diet change and exercise. It would also require a system to ensure that healthcare workers on the ground are properly trained and regularly in touch with families, if it is scaled up. "Some of the quality checks are in-built [in the existing programme], but we can create a programme where evaluation is concurrent," said Prabhakaran.

At the same time, "given that the government of India is setting up health and wellness clinics with non-physician healthcare providers, who would constantly engage with the community, it is feasible to apply this approach at the large scale", said Prabhakaran. Over 75,000 of these centres have been operationalised and the government aims to double these by December 2022, according to an April 2021 press release by the health ministry. Scaling up this study approach, to health and wellness centres, could also bring down the monitoring cost per family per year, the study said.

"The community health worker would be central to its success," said Prabhakaran, who added that healthcare workers can be trained in large numbers across the country. "More research is needed on the implementation of this approach on a larger scale, on how to make it sustainable and on how to incorporate it into India's health system," said Prabhakaran.

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