The increase in non-communicable diseases among the non-elderly around the world is doubly alarming for countries like Pakistan with a youthful demography. Most of the problems stem from unhealthy diets, sedentary lives and, as always, a lack of information
It all started three years ago when Zaid Sohail realised that if he did not change his dietary habits and lifestyle he would die.
Lunch at the office would be ordered from some nearby fast food joint on a daily basis. On most days, the meal would be incomplete without mouth-watering pastries from the nearby bakery chain. And teatime would always be the perfect pick-me-up with cake rusks or baqar khani dunked in doodh patti, to re-energise.
At 24 years, his life was a whirl of oversized beef burgers, large packs of fries on the side and pizzas, downed with generous portions of icy cold fizzy drinks. After work, he loved hanging with friends till late in the night. Post-midnight, it would be his time alone in his bedroom, enjoying a movie over a late-night meal — usually a kebab roll, fries and a can of cola.
A ticking time bomb, Sohail who was suffering from hypertension, had no idea that poor diet was found to be a leading cause of death (one among five), among young adults in 2017.
NCDs kill 41 million people each year. That's equivalent to 71 percent of all deaths globally.
This was affirmed by a study published earlier this year in The Lancet, a weekly medical journal. The study looked into the relationship between our eating habits and chronic non-communicable diseases (NCDs) by studying dietary consumption between 1990 and 2017 in 195 countries. The focus of the study was 15 types of foods or nutrients — fruits, vegetables, nuts and seeds, legumes, whole grains, fibre, calcium, milk, omega-3 fatty acids from seafood, polyunsaturated fats, trans fats, red meat, processed meat, sugary drinks and sodium.
The study highlighted the need for improving diet across nations by pointing out the potential impact of suboptimal diet on NCD mortality and morbidity.
According to the World Health Organization, NCDs, including cardiovascular diseases (like heart attacks and strokes), cancers, respiratory diseases (including asthma) and diabetes — also known as lifestyle diseases — kill 41 million people each year. Of these, 15 million are premature deaths of people aged between 30 and 69.
With 64 percent of the Pakistani population younger than 30 and 29 percent between the ages of 15 and 29, this should be a clarion call. The country has more young people than it has ever had and this trend will continue to increase until 2050, say demographers.
Pakistan has been feeling the impact of NCDs for years, points out Dr Sania Nishtar, who co-chairs the WHO's high-level independent commission on non-communicable diseases. "NCDs have been known to be the biggest killers since the early 1990s — trans fats, refined sugar, salt, energy-dense, nutrient-poor processed foods increase the risk of NCDs," says Dr Nishtar, who is also a special assistant to Prime Minister Imran Khan on poverty alleviation and social protection.
The four lifestyle factors strongly associated with NCDs include diet, lack of physical activity, alcohol intake and tobacco consumption.
But these diseases, once thought to be primarily afflicting the elderly, are now hounding the country's young population.
According to the National Diabetes Survey of Pakistan (2016-17), 26 percent of the population is diagnosed with diabetes, in which 14 percent is overweight, 44 percent is obese and 46 percent is hypertensive.
The situation is grave indeed. Sixty-five percent of the mortality in Pakistan can be attributed to NCDs, according to Dr Romaina Iqbal, an associate professor at Aga Khan University Hospital. The WHO's NCD Country Profile 2018 put the percentage at 58 percent. And while infectious diseases may still be killing more people in Pakistan, Dr Iqbal says NCDs are "equally concerning".
The four lifestyle factors strongly associated with NCDs include diet, lack of physical activity, alcohol intake and tobacco consumption.
Tobacco use kills around 160,100 in Pakistan each year. That is 438 people killed every day.
At least 12 Pakistanis die every hour due to heart attack and the main reason behind it is excessive smoking among the country's youth, according to the general secretary of Pakistan Heart Association (Panah), Chaudhry Sanaullah Ghumman.
Sounding the alarm bells louder, Ghumman adds that tobacco use is the second leading cause of heart disease with approximately 12 percent of all heart disease deaths being caused by smoking.
Other tobacco control advocates also paint a grim picture, quoting statistic after statistic. The Tobacco Atlas (2018) found that there are around 23.9 million tobacco users in Pakistan. Of these, 15.6 million are cigarette smokers.
Then there are the numbers that Pakistan simply does not have. While globally cancer is ranked the second leading cause of death and the single-most-important barrier to increasing life expectancy, the specifics about Pakistan are hard to come by. The country has no cancer registry to project its cancer burden and give direction for a clear cancer control and prevention policy.
However, the latest figures by the World Cancer Research Fund ranks Pakistan second on the list of countries with the highest incidence of oral cancer. In fact, oral cancer is the most common type of cancer among men in Pakistan and doctors blame consumption of chewing tobacco for this.
Three years ago, Sohail went through a life-changing experience. He woke up in the middle of the night with agonising pain in his chest, followed by a huge bout of vomiting.
"I was taken to the nearest hospital, where the doctors did an electrocardiogram (ECG) to check my heart's rhythm," recalls Sohail. It came out clear and the doctor prescribed an antacid and sent me home."
Sohail remained unconvinced. The pain he had felt that night had clearly left a mark on him. "I suffered from anxiety and the excruciating pain would return again and again," he explains. "It was so real, I reeled from it."
In one year, the young man got 32 ECGs done, only to get the same results.
He became paranoid and depressed. Post-work friends hangouts had lost their appeal. And he also developed a fear of air travel and stopped flying, afraid that he would have a heart attack on the plane.
He could not shake the feeling that he was about to die.
The young man consulted top cardiologists and was advised a battery of blood tests.
"My bad cholesterol, which should be under 150, had shot up to 460. I was extremely overweight," he says. At 5 feet 6 inches, this young businessman weighed 136 kg. He now aims to drop his weight to 75kg to 80kg. Upon deeper inspection, Sohail had a realisation.
"I realised it was nothing but the food that I was eating," Sohail says. "That would be the death of me and I did not want to die a glutton just when I was starting my life."
Youngsters themselves seem motivated to change their lifestyles and tech companies are also rushing to bank on these new trends. There are apps that tell users how many steps they have taken in a day and how many calories they need to burn.
Many, like Sohail, lead an on-the-go lifestyle, leaving little time for self-care. It seems urbanisation, adopting a Western lifestyle, a palate change (from chapati and malai to burgers, noodles and cheese) and moving away from simple home-cooked meals to highly processed ones, have led to an increase in such diseases in Pakistan. "A decrease in consumption of dairy products, fruits and vegetables is worsening the situation," adds Dr Iqbal.
Some would question why our South Asian forefathers did not suffer from as many NCDs. Afterall, they were having mithai (sweetmeats), malai (cream), papay (rusks) dunked in chai (tea), cakes, curried meals with a thick top layer of ghee etc., on a daily basis.
The answer is simple. "Their lifestyle was more active than ours," points out Fayza Khan, former president of the Pakistan Nutrition and Dietetic Society. "They walked a lot more, covering long distances in a day. Women, too, back then did a lot of physical labour at home." In the absence of kitchen electrical appliances, women pounded and crushed spices on heavy stone (sil-batta).
"People consumed desi ghee and not vanaspati [desi vegetable oil] back then," adds Dr Syed Muhammad Ghufran Saeed, an assistant professor in the department of food science and technology at the University of Karachi. "Natural trans fats are found to be less harmful than artificial ones which are produced during hydrogenation," he says.
The problem goes beyond the eating habits of youngsters like Sohail.
"Did you know that on average, a Pakistani consumes something like 17kg of oil in a year, and most of it is in the form of vanaspati?" asks Dr Saeed. "This speaks volumes of the kind of lifestyle we lead."
In fact, Dr Saeed says, the main cause of NCDs is the consumption of food made of trans fats. "These are a major cause of heart diseases such as strokes or brain haemorrhage and cause an increase of cholesterol in our blood," he says. This problem is also not specific to Pakistan. As the Lancet study found, suboptimal diets are an important preventable risk factor for NCDs around the world.
But other countries seem to be taking steps to remedy this.
The WHO recommends that, by 2023, the use of trans fats should be lowered to less than 0.2 percent. In India, the limit of trans fats in packaged food was 10 percent in 2013. It was reduced to five percent in 2017. The country plans to bring the number down to zero by 2022 - a year ahead of the timeline set by the WHO.
Dr Saeed is unsure if Pakistan can make similar progress. The country's food quality standards have fixed the limit at 10 percent (and many packaged foods continue to use more than that). In the West, food manufacturers are required to state the amount of trans fats in their food product if the level exceeds 0.5 milligrammes per serving. This is not the case in Pakistan.
"In the absence of a policy that sets a limit to the levels of, say, trans fats or sodium or sugar in a food item, and which is backed by law, even the food regulatory authority cannot do anything," says Dr Saeed. Of course, most food manufacturers do not feel the need to voluntarily provide that information by labelling the ingredients.
Dr Khan says there is an urgent need for the government to develop a clear set of criteria or targets to reduce the amount of salt, trans fats and sugar added to food. At the same, time it must be made mandatory to display ingredients and their levels on food packaging. People need complete nutrition information to make healthier choices, Dr Khan adds. In its absence, monitoring the amounts of salt, fat and sugar consumed is difficult. When making informed choices is more difficult, many simply turn towards quick-fix diets, confusing them with healthy eating.
Despite his work schedule, Sohail led a physically active life. He went running, cycling, swimming and played squash thrice a week or so. This probably helped neutralise the food binge he was on to some extent. But to lose weight quickly, he decided to join a gym and also took his trainer's advice to try the 42-day challenge. "I carried out the diet three times and realised it was not a good idea. It was not good for my system, my stomach just could not take it," he says.
Healthcare professionals, including Dr Khan, are not in favour of these quick-fix regimes unless monitored by a dietician.
"I marvel at the way gym instructors promote weight-loss programmes or do a dietary analysis of their clients when they have no such qualifications," she says. For example, Keto, a diet regimen to lessen seizures among kids suffering from epilepsy, suddenly became a popular diet among many young Karachiites two years ago. Today, research suggests that the diet has its own set of side effects, especially for people with diabetes complications. For women specifically, says Dr Khan, Keto has the potential to contribute to cognitive and functional deficits in their offspring.
"When you disturb a person's natural metabolism, it is bound to have consequences," warns Dr Khan. "To combat and neutralise that, the instructors start recommending pills for one ailment or the other."
Dr Khan, who currently heads the nutrition department at the Kidney Centre's Post-Graduate Training Institute, stresses that gym instructors need qualified and registered dieticians who can assess dietary regimens and help clients reach goals in a healthier manner. She believes that instructors should not be allowed to practice this "form of quackery" which remains under the radar of authorities.
Sohail was lucky and realised soon that he needed professional help and sought the guidance of a psychiatrist as well as a dietician.
Detection, screening and treatment of NCDs, as well as palliative care, are key components of the response to NCDs.
He banished all the oversized fast-food meals, said goodbye to the bakery shop and replaced the fizzy sugary drinks with plain water.
"I eat simple home-cooked food and do regular exercise. I do not go on diets anymore. I eat everything — meat, chapatti, fruit, etc., just bringing discipline in my chaotic life has helped tremendously," says Sohail. He also used to have trouble sleeping until he realised that if he exercises, he sleeps better.
After being a chain-smoker, he has also quit cigarettes.
But while Sohail may have had the willpower to cast out all the "bad" food from his life, not everyone is as successful. Sellers of these foods continue, and will continue, to lure millions through enticing photos of mouth-watering burgers or pizzas on huge roadside billboards, and food joints will continue to offer deals that you just cannot resist.
While on the one hand are youngsters whose unhealthy lifestyles and dietary habits are pushing them towards diseases, on the other, there are families who simply cannot afford to provide their loved ones with healthy eating options.
The National Health Services' National Nutrition Survey of 2018 (NNS) found that over 50 percent of Pakistani families are unable to consume even two meals a day and 36.9 percent of Pakistani households are food insecure — unable to meet their basic nutritional needs. Over 40 percent of children suffer from chronic malnutrition.
"The survey clearly shows nutrition transition between childhood and adolescence, and also has information on diets and risk factors for adult women and adolescent boys and girls," says Dr Zulfiqar Bhutta, the nutrition expert who also led the survey. "I think we have enough data on NCDs," he adds, "it is now time to spend on action."
This inaction is something even Prime Minister Khan appears concerned about. On his very first address to the nation, he pulled out images showing brains of two two-year-olds - one with normal growth, the other stunted due to insufficient nutrition. He claimed that this was a key challenge his government would address. "We are among the top five countries in the world where children die because of malnutrition..." he had said.
The NNS 2018 shows stunting to be at 40.2 percent (although it is down from 43.7 percent in 2011).
"I think we have enough data on NCDs, it is now time to spend on action."
"NCDs require sustained policies at the national level, not standalone isolated interventions and activities" points out Dr Anjum Javed, director health programmes at the Ministry of National Health Services, Regulations and Coordination. Although he points out, there are separate policies for mental health, heart, cancer and diabetes, these need to be put together under one plan to be effective.
Dr Javed's ministry has been working on a national strategic paper that could hold some solutions. Because health is a provincial subject, the paper will act as a guiding document for the provinces to "devise their own policies and project documents," he says. He is hopeful that with strong advocacy for it at the federal level, and immense interest from international donor agencies, the plan is more likely to see the light of day.
Slowly, but surely, things are changing.
Around the urban stretch globally, more wellness gyms and restaurants that label calories are popping up. Yoga has become popular, as have classes that promote mindfulness. There are green juice bars coming up and, elsewhere around the world, there is also a growing demand for plant-based meat. These trends are making their way to Pakistan too, but only time will tell if they are fads.
In more concrete steps, since over a year or so, fizzy drinks have been banned from school canteens and cafeterias in Sindh, Khyber Pakhtunkhwa and Punjab.
Turn your sedentary lifestyle into pursuing an outdoorsy, physically active one, have a balanced diet, enjoy home-cooked meals and avoid eating late meals and eating out
"It's a good start and fairly effective, although there are some elite schools who are getting away from this ban," says Baela Raza Jamil, director of programmes at Idara-e-Taleem-o-Aagahi. "But the ban will only help in behaviour change if these are also not available outside the school gate."
Youngsters themselves seem motivated to change their lifestyles and tech companies are also rushing to bank on these new trends. There are apps that tell users how many steps they have taken in a day and how many calories they need to burn. Another recently-launched app called Kurbo claims to be a "science-proven" behaviour change programme, derived from Stanford University's Pediatric Weight Control Programme. The app helps create healthier lifestyles for kids and teens by virtually coaching them through traffic light systems, with green foods being healthy, yellow being foods that one should eat in moderation and red foods being foods that one should "stop and think how to budget in."
Ironically, while we hear of more young people suffering from diseases that were previously associated with the elderly, today life expectancies are higher. "People are living longer but the quality of life has gone down," Dr Iqbal reiterates.
The solution she believes is in the hands of young Pakistanis. "Turn your sedentary lifestyle into pursuing an outdoorsy, physically active one, have a balanced diet, enjoy home-cooked meals and avoid eating late meals and eating out," she advises.
The writer is a freelance journalist. She tweets @Zofeen28.
Published in Dawn, EOS, September 22nd, 2019
While trans fats — unsaturated fats — are found naturally in meat and dairy, it is the artificial trans fats (vanaspati) that is of concern to dieticians. These are formed by adding hydrogen to vegetable oil to form a semi-solid product known as partially hydrogenated oil.
There have been enough studies to prove that eating foods that contain trans fats can prove lethal for your heart and cause higher "bad" LDL cholesterol and lower "good" HDL cholesterol levels. Next time you are buying groceries, read and check the ingredients more carefully to see if it says "partially hydrogenated oil" and decide whether you want to banish vanaspati from your life once and for all.
You may think popcorn is a healthy snack, but that is not true if you consume the microwavable ones (as opposed to popping kernels over a stove). Check if your popcorn has vegetable shortening (a cheap substitute for butter which is made by adding hydrogen to vegetable oil). Also, see if margarine and vegetable oils used in the product have partially hydrogenated oils; these would contain trans fats. A healthier choice would be products that use olive oil, butter or coconut oil — but the key is moderate use.
Fast-food chains often fry food in oil that contains trans fats. On top of that, cooking temperatures are high and cause the trans fat content of the oil to increase slightly. This content increases each time the same oil is reused for frying.
While most multinational chains follow some regulations for the type of oil that is used, there is little check on local fast-food chains.
To produce flakier pastries, soft sponges of cakes and doughnuts that melt in your mouth, bakery shops use vegetable shortening, making these scrumptious treats high in trans fats. Unfortunately, no nutrition information is printed on the labels of these products so you cannot know if they have used hydrogenated oil or butter (which is more expensive compared to margarine or other shortening).
While these milk substitutes may make your tea or coffee taste better, they also contain sugar and oil. In recent years, many brands have reduced their trans fat content, so read the label carefully and choose which one to take home. Also, always be sceptical. The product is likely to have small amounts of trans fats even if it is advertised to be trans-fat-free on the packaging.
If the product is sold as a frozen dessert instead of ice cream, it has likely been made using non-dairy creamer rather than milk.
Many ready-to-eat frozen food items that need two to three minutes' cooking including parathas, meat patties, quiches, sausages, drumsticks, etc., are available in the market. These are likely to contain trans fats.
Savoury snacks like daal mot, khatta meetha chewra and namak paaray, that come to your aid when hunger strikes, and the achaars and chutneys that can enhance the taste of any meal, have the same killer ingredients that need to be banished from your home.
To prevent pickles from getting mouldy and invaded by fungi and bacteria, as well as to increase their shelf life, oil is added, which may contain trans fats. In addition, achaars, chutneys and other savoury snacks contain generous amounts of salt. This increased sodium causes water retention and high blood pressure. It also makes your kidneys work overtime. And high salt content also reduces calcium absorption, which is a leading cause of low bone density.