**1. Introduction**

Cardiovascular disease is reported to be the leading cause of death in world. In 1998, 12.4 million people died of heart attack and stroke. Of these 78% were in low and middle income countries. The high income countries had lower death rates because of better preventive and treatment program [1]. Though, several clinical and biochemical risk factors have been identified, the role of psychological factors are also gaining importance during the past few decades. Several risk factors have been identified to be associated with coronary heart disease (CHD) which include causative risk factors (hypertension, hyperlipidemia and diabetes), conditional risk factors (triglycerides and lipoprotein), and predisposing risk factors (obesity, physical activity, sex, family history, socioeconomic factors, insulin resistance and psychological factors) [2]. Evidence of various studies has shown a strong association in psychological stress and CHD. Cardiovascular disorders pose a major health problem for industrialized societies in terms of excess of morbidity and mortality. It is evident from the review of literature that there is a strong relationship between coronary heart disease and some psychological factors. Psychological variables like stress, personality, anxiety and lifestyle are contributing along with high blood pressure, obesity; lack of exercise,

cigarette smoking and high blood cholesterol to the development of CHD [3]. In present study, a comparative study is carried out between coronary heart disease patients and non-coronary individuals in relation to lifestyle.

Large number of clinical and biochemical factors have been identified in development of CHD, the role of psychosocial factors are also gaining importance during the past few decades. The World Health Organization has stated that since 1990, 80–90% of people dying from CHD had one or more risk factors associated with lifestyle [4]. Lifestyle is a way person lives. This includes patterns of individual's health behaviour, social interactions, attitudes, values, belief and essentially the way the person perceived by himself/herself and at times also how he/she perceived by others. Lifestyle is one of the major factors which have shown a strong association with CHD [5]. Lifestyle is based on subjective perception, is purposeful and goal directed. It is motivated by a desire to overcome feeling of inadequacy coupled with an urge to succeed. The general goals of lifestyle are to understand, predict, and control life and self. Lifestyle has been found, as pointed out earlier, to have influence on individual's health, adjustment to environment, psychosomatic and psychiatric illness [6]. Health psychologists found that healthy lifestyle and dietary intake are associated with positive effects on blood cholesterol [7]. Diet, sleeping pattern, smoking, and alcohol taking habits have a negative effect on health [7].

Russek and Zohman [8] observed in young coronary patients that prolonged emotional strain was associated with job responsibility. The Framingham study had demonstrated the significance of lifestyle, employment and interpersonal stress. By showing that in males under 65, aging worries and daily stress and tension were associated with a greater risk of developing CHD, while for males and females over 65; marital dissatisfaction or disagreements were risk factors for CHD [9]. A diet high in fat, obesity and lack of exercise increases the risk of heart disease. Tobacco use, whether it is smoking or chewing tobacco, increases risk of cardiovascular disease [10].

There is a positive relationship between heart disease and fat intake, obesity, smoking and lack of exercise. The relationship between smoking and risk for CHD is simple and direct. Smoking has several negative effects on cardiovascular system (MacDougall, 1983, cited in [6]). Job dissatisfaction and work load in males emerged as a factor of predictive of CHD [6].

In the present study, lifestyle is measured on the basis of heath and behaviour pattern, job involvement, social interactions, intimacy, locus of control and values.

#### **2. Status in India**

In India, in the past five decades, rates of coronary disease among urban populations have risen from 4 to 11% and four Indians die every minute due to heart disease. In India, 50% of heart patients are under 45 years of age [11]. CHD is emerging as a major cause of death in India. It has been projected that 15 years from now India would have highest CHD deaths compared to any other country [12]. ICMR and WHO have predicted that cardiovascular diseases would be the most important cause of mortality and morbidity in India by the year 2015 [13]. Data from Christian Medical College, Vellore and All India Institute of Medical Sciences, New Delhi, over a period of 30 years showed a decline in admission for rheumatic heart disease (RHD) and increase in admission for CHD [14]. A comparative study in Singapore on Indians and Chinese, revealed stronger cardiovascular reactivity to stress among Indians than compared to Chinese men [15]. Chronic anxiety and tension have been suggested as factors in the development of CHD. There is strong evidence supporting prognostic associations with social isolation and low perceived

**157**

*The Role of Lifestyle in Development of Coronary Heart Disease*

to contribute to this significant domain of research.

emotional support and unhealthy lifestyle behaviors in the development of CHD [16]. In India, it has been observed that there is age related increase in CHD. The incidence of myocardial infarction (MI) was more common in urban India than rural areas of India [17]. Studies in India have shown that heart attacks in India occur 10 years earlier than in West. Hence it is needed to undertake well designed prospective studies for evaluation of CHD in relation to psychological factors [18]. According to Theorell et al. [19], cases of CHD may increase from about 2.9 crore in 2000 to as many as 6.4 crore in 2015.The prevalence rates among younger adults (age group of 40 years and above) are also likely to increase. Prevalence rates among women will keep pace with those of men across all age groups. Data also suggest that prevalence rates of CHD in rural populations will remain lower than

In brief the rationale of the study is the limited research available in this area related to psychological factors in India. This study was carried on matched subjects

Lifestyle is one of the major factors which have shown a strong association with CHD [5]. Lifestyle is based on subjective perception. The behaviour pattern of an individual as expressed by his motives, his manners of coping and other factors including values, social and family satisfaction, job satisfaction and work style are called lifestyle. In the present study lifestyle is measured on heath and behaviour pattern, job involvement, social interactions, intimacy, locus of control and values. Research work has been done linking lifestyle, personality and coronary heart disease. It shows that Type A behaviour pattern (TABP) promotes a lifestyle which facilitates exposure to range of social, personal and occupational stresses which emerges into a coronary heart disease. Wright's identified five separate paths to coronary artery disease that are inherited risk based on family history, risks that accrue from personal lifestyle choices such as overeating and lack of exercise, anger directed inward, anger directed outward that is combined with a sense of time urgency and chronic activation and the traditional Type A pattern identified by Rosenman and Friedman. Regular physical activity in the context of work, recreation or an exercise training programme is associated with a marked reduction in heart disease related deaths in patients. Exercise has positive effects on the cardiovascular system that reduce risk for coronary artery disease and myocardial ischemia. Exercise tends to reduce heart rate, it improves the efficiency of the heart and it reduces blood pressure. It improves efficiency in the respiratory system so that oxygenation of blood and supply of oxygen to heart is better. Exercise reduces weight and there is a beneficial effect on cholesterol, triglycerides and ratio of HDLs to LDLs. The National High Blood Pressure Education Program recommended four changes in lifestyle to help, prevent or manage hypertension, since hypertension is a major modifiable risk factor for CHD. These are weight control, reduced salt intake, increased exercise and moderate alcohol consumption. Diet has a direct and important role in heart disease that goes beyond cholesterol. A diet high in saturated fat increases the risk of heart disease and stroke. Gender linked risk cannot be changed but high blood pressure, elevated cholesterol and smoking can be significantly reduced by life changes. Simple adjustments to diet and exercise have positive effects on both cholesterol and blood pressure. Tobacco use, whether it is smoking or chewing tobacco, increases risk of cardiovascular disease. Passive smoking is also risk factor for CHD. The relationship between smoking and risk for CHD is simple and direct. Incidence of heart attacks and sudden cardiac deaths is directly related to the number of cigarettes smoked on a regular basis. Cigarette smoking is the most preventable cause of coronary heart disease. The Framingham data show that men who smoke have up to 10 times the likelihood of sudden death compared to nonsmoker. Smoking interferes with the oxygen carrying capacity of blood, it

*DOI: http://dx.doi.org/10.5772/intechopen.86866*

that of urban population [17].

#### *The Role of Lifestyle in Development of Coronary Heart Disease DOI: http://dx.doi.org/10.5772/intechopen.86866*

*Inflammatory Heart Diseases*

and non-coronary individuals in relation to lifestyle.

cigarette smoking and high blood cholesterol to the development of CHD [3]. In present study, a comparative study is carried out between coronary heart disease patients

Large number of clinical and biochemical factors have been identified in development of CHD, the role of psychosocial factors are also gaining importance during the past few decades. The World Health Organization has stated that since 1990, 80–90% of people dying from CHD had one or more risk factors associated with lifestyle [4]. Lifestyle is a way person lives. This includes patterns of individual's health behaviour, social interactions, attitudes, values, belief and essentially the way the person perceived by himself/herself and at times also how he/she perceived by others. Lifestyle is one of the major factors which have shown a strong association with CHD [5]. Lifestyle is based on subjective perception, is purposeful and goal directed. It is motivated by a desire to overcome feeling of inadequacy coupled with an urge to succeed. The general goals of lifestyle are to understand, predict, and control life and self. Lifestyle has been found, as pointed out earlier, to have influence on individual's health, adjustment to environment, psychosomatic and psychiatric illness [6]. Health psychologists found that healthy lifestyle and dietary intake are associated with positive effects on blood cholesterol [7]. Diet, sleeping pattern, smoking, and alcohol taking habits have a negative effect on health [7]. Russek and Zohman [8] observed in young coronary patients that prolonged emotional strain was associated with job responsibility. The Framingham study had demonstrated the significance of lifestyle, employment and interpersonal stress. By showing that in males under 65, aging worries and daily stress and tension were associated with a greater risk of developing CHD, while for males and females over 65; marital dissatisfaction or disagreements were risk factors for CHD [9]. A diet high in fat, obesity and lack of exercise increases the risk of heart disease. Tobacco use, whether it is smoking or chewing tobacco, increases risk of cardiovascular

There is a positive relationship between heart disease and fat intake, obesity, smoking and lack of exercise. The relationship between smoking and risk for CHD is simple and direct. Smoking has several negative effects on cardiovascular system (MacDougall, 1983, cited in [6]). Job dissatisfaction and work load in males

In the present study, lifestyle is measured on the basis of heath and behaviour pattern, job involvement, social interactions, intimacy, locus of control and values.

In India, in the past five decades, rates of coronary disease among urban populations have risen from 4 to 11% and four Indians die every minute due to heart disease. In India, 50% of heart patients are under 45 years of age [11]. CHD is emerging as a major cause of death in India. It has been projected that 15 years from now India would have highest CHD deaths compared to any other country [12]. ICMR and WHO have predicted that cardiovascular diseases would be the most important cause of mortality and morbidity in India by the year 2015 [13]. Data from Christian Medical College, Vellore and All India Institute of Medical Sciences, New Delhi, over a period of 30 years showed a decline in admission for rheumatic heart disease (RHD) and increase in admission for CHD [14]. A comparative study in Singapore on Indians and Chinese, revealed stronger cardiovascular reactivity to stress among Indians than compared to Chinese men [15]. Chronic anxiety and tension have been suggested as factors in the development of CHD. There is strong evidence supporting prognostic associations with social isolation and low perceived

**156**

disease [10].

**2. Status in India**

emerged as a factor of predictive of CHD [6].

emotional support and unhealthy lifestyle behaviors in the development of CHD [16]. In India, it has been observed that there is age related increase in CHD. The incidence of myocardial infarction (MI) was more common in urban India than rural areas of India [17]. Studies in India have shown that heart attacks in India occur 10 years earlier than in West. Hence it is needed to undertake well designed prospective studies for evaluation of CHD in relation to psychological factors [18]. According to Theorell et al. [19], cases of CHD may increase from about 2.9 crore in 2000 to as many as 6.4 crore in 2015.The prevalence rates among younger adults (age group of 40 years and above) are also likely to increase. Prevalence rates among women will keep pace with those of men across all age groups. Data also suggest that prevalence rates of CHD in rural populations will remain lower than that of urban population [17].

In brief the rationale of the study is the limited research available in this area related to psychological factors in India. This study was carried on matched subjects to contribute to this significant domain of research.

Lifestyle is one of the major factors which have shown a strong association with CHD [5]. Lifestyle is based on subjective perception. The behaviour pattern of an individual as expressed by his motives, his manners of coping and other factors including values, social and family satisfaction, job satisfaction and work style are called lifestyle. In the present study lifestyle is measured on heath and behaviour pattern, job involvement, social interactions, intimacy, locus of control and values. Research work has been done linking lifestyle, personality and coronary heart disease. It shows that Type A behaviour pattern (TABP) promotes a lifestyle which facilitates exposure to range of social, personal and occupational stresses which emerges into a coronary heart disease. Wright's identified five separate paths to coronary artery disease that are inherited risk based on family history, risks that accrue from personal lifestyle choices such as overeating and lack of exercise, anger directed inward, anger directed outward that is combined with a sense of time urgency and chronic activation and the traditional Type A pattern identified by Rosenman and Friedman. Regular physical activity in the context of work, recreation or an exercise training programme is associated with a marked reduction in heart disease related deaths in patients. Exercise has positive effects on the cardiovascular system that reduce risk for coronary artery disease and myocardial ischemia. Exercise tends to reduce heart rate, it improves the efficiency of the heart and it reduces blood pressure. It improves efficiency in the respiratory system so that oxygenation of blood and supply of oxygen to heart is better. Exercise reduces weight and there is a beneficial effect on cholesterol, triglycerides and ratio of HDLs to LDLs. The National High Blood Pressure Education Program recommended four changes in lifestyle to help, prevent or manage hypertension, since hypertension is a major modifiable risk factor for CHD. These are weight control, reduced salt intake, increased exercise and moderate alcohol consumption. Diet has a direct and important role in heart disease that goes beyond cholesterol. A diet high in saturated fat increases the risk of heart disease and stroke. Gender linked risk cannot be changed but high blood pressure, elevated cholesterol and smoking can be significantly reduced by life changes. Simple adjustments to diet and exercise have positive effects on both cholesterol and blood pressure. Tobacco use, whether it is smoking or chewing tobacco, increases risk of cardiovascular disease. Passive smoking is also risk factor for CHD. The relationship between smoking and risk for CHD is simple and direct. Incidence of heart attacks and sudden cardiac deaths is directly related to the number of cigarettes smoked on a regular basis. Cigarette smoking is the most preventable cause of coronary heart disease. The Framingham data show that men who smoke have up to 10 times the likelihood of sudden death compared to nonsmoker. Smoking interferes with the oxygen carrying capacity of blood, it

reduces bioelectrical control and finally smoking increases the tendency to platelet aggregation and clot formation. Clots increase the potential for thrombosis and fatal coronary. Russek and Zohman [8] observed emotional strain associated with job responsibility in young coronary patients. There is a positive association between job dissatisfaction and CHD. Karasek's group in Sweden [18] explored the relationship of the kinds of work stresses that may be associated with cardiac pathology. They had given a model which links high work demands with an inability to make decisions. Theorell's prospective study of 6500 middle aged males in Swedish construction industry found dissatisfaction with domestic and working life was predictive of suffering a myocardial infarction during subsequent 2 years. In a study of London transport bus drivers and conductors, results showed that bus drivers had significantly higher incidence of heart disease than bus conductors because of more responsible and stressful nature of their work. The Framingham study showed that men undergo in frequent work promotions sustained an increased chance of developing CHD. A supportive social network and having community ties promote emotional and physical wellbeing. Some studies validate positive relationship between social support and CHD mortality. Studies on marital status have repeatedly shown that the single widowed or divorced have higher CHD mortality rates compared to their counter parts. It was also found that interpersonal relationship and marital dissatisfaction or disagreements were risk factors for CHD.

The association between values and attitudes towards life was studied in cross cultural context in Japanese young men.

It was found that Japanese who maintain their traditional way of life, values and language after their emigration to US, do not have increased rate of CHD. In study of Japanese- American males found that those with the lowest level of social affiliation had double the risk of developing CHD. The rate of CHD mortality increases due to smoking, alcohol and foods rich in fats, less exercise, lack of control over one's working environment, reduced levels of social support, the cumulative life cycle experience of belonging to a social class or nation undergoing rapid urbanization and industrialization.

The main objective of this research was to study the role of lifestyle in development of CHD and hypothesis formulated was patients of coronary heart disease (CHD) would score higher on subscales of lifestyle as compared to matched non-CHD individuals.

This being a study on stress, anxiety, type A behaviour pattern and lifestyle variable of the patients of coronary heart disease (CHD) and their matched normal patients for the present study were selected from cardiac care unit (CCU) of hospitals from Pune city. During the survey for CHD patients 10:1 ratio of male to female was observed. As, there is a physiological cause that men having a greater risk of heart disease than women do, because, the higher levels of high density lipoprotein (HDL) cholesterol, which helps to slough off the more lethal low density lipoprotein (LDL), these higher HDL levels appear to be linked to premenopausal women's level of estrogen. Estrogen diminishes sympathetic nervous system arousal, which may add to protective effect against heart disease seen in women. So in the present study only male CHD patients were selected. Out of 121 male CHD patients admitted in CCU's of various hospitals in Pune, 81 CHD male patients agreed to participate in the present study. In the present study selection of 81 matched normal was done by keeping the patients in view. The patients and normals were matched, one to one on the variables of age, education, occupation, family type and socioeconomic status. These 81 male CHD patients met the inclusionary criteria, which were as follows:

Age: 30–60 years; education: minimum S.S.C. passed; occupation: employed; family type: nuclear family is staying with wife and children, and joint family is staying with wife, children and parent; socioeconomic status: minimum income

**159**

*The Role of Lifestyle in Development of Coronary Heart Disease*

tion of interview schedule is given in Appendix A. Description of the sub-dimensions is given below.

as higher scores indicate more risky lifestyle.

indicate external locus of control.

Following tools and measures we used for data collection.

age, education, occupation, family type and socioeconomic status.

Rs 10,000 per annum. The normals were selected after the medical checkup by the physicians who labeled them as normal as they were not suffering from any disease.

Personal data sheet: A personal data sheet comprising 14 items was prepared and was required to be filled in by the patients and normal before the actual administration of psychological scales. The items were designed to get the information about

Interview schedule: To measure lifestyle in CHD patients and normal individuals, structured interview schedule was prepared on the basis of operational definition of lifestyle. Interview schedule includes four subparts in which questions are formulated beforehand and asked in a set order in a specified manner. The descrip-

A. Health behaviour pattern: It includes information about sleeping habits, dietary habits, daily exercise, smoking habits. To find out health behaviour pattern three questions were framed to get detailed information about sleeping habits, four questions for dietary habit, four questions for daily exercise, six questions for smoking habits. The coding of the responses is quantified. A five point rating scale, that is, always, often, sometimes, rarely, and never is used to measure the responses of person. Higher the scores on sleeping habits, dietary habits and smoking habits indicates more risky lifestyle whereas lower scores indicate healthy lifestyle. Lower scores on daily exercise indicate healthy lifestyle where

B. Social interactions: It includes the information about social awareness and social life of the person. To get detailed information about social interactions 16 questions were framed. The coding of the responses is quantified. A five point rating scale is used to measure the responses of the person. Higher scores on social interactions indicate healthy lifestyle whereas lower scores indicate more risky lifestyle.

C. Intimacy: It includes the information about family and personal life activities. Intimacy is that quality of being close and affectionate with another person. It can occur with or without sexuality. To get detailed information eight questions were framed. The coding of the responses is quantified. A five point rating scale is used to measure the responses of the person. Higher scores on intimacy indicate healthy lifestyle whereas lower scores indicates more risky lifestyle.

D. Locus of control: It includes information about the individuals own interpretation of personal control over illness and health. Locus of control refers to the belief about location of control of behaviour by the subject. This locus is classified as external and internal. Individuals with external control think that their behaviour is controlled by the external forces like chance, luck, fate, some influential person or external circumstances. Individuals with internal control believe that their behaviour is controlled by the forces which are within themselves and the event is contingent upon their own behaviour. Eleven questions were framed to get detailed information about locus of control related to health and illness aspects. A five point rating scale is used to measure the responses of the person. Higher scores indicate internal locus of control whereas lower scores

E. Values: It includes the information of two values namely money and religion of the person. Values hold a central place in culture, identity and lifestyle of the

*DOI: http://dx.doi.org/10.5772/intechopen.86866*

#### *The Role of Lifestyle in Development of Coronary Heart Disease DOI: http://dx.doi.org/10.5772/intechopen.86866*

*Inflammatory Heart Diseases*

reduces bioelectrical control and finally smoking increases the tendency to platelet aggregation and clot formation. Clots increase the potential for thrombosis and fatal coronary. Russek and Zohman [8] observed emotional strain associated with job responsibility in young coronary patients. There is a positive association between job dissatisfaction and CHD. Karasek's group in Sweden [18] explored the relationship of the kinds of work stresses that may be associated with cardiac pathology. They had given a model which links high work demands with an inability to make decisions. Theorell's prospective study of 6500 middle aged males in Swedish construction industry found dissatisfaction with domestic and working life was predictive of suffering a myocardial infarction during subsequent 2 years. In a study of London transport bus drivers and conductors, results showed that bus drivers had significantly higher incidence of heart disease than bus conductors because of more responsible and stressful nature of their work. The Framingham study showed that men undergo in frequent work promotions sustained an increased chance of developing CHD. A supportive social network and having community ties promote emotional and physical wellbeing. Some studies validate positive relationship between social support and CHD mortality. Studies on marital status have repeatedly shown that the single widowed or divorced have higher CHD mortality rates compared to their counter parts. It was also found that interpersonal relationship

and marital dissatisfaction or disagreements were risk factors for CHD.

cultural context in Japanese young men.

tion and industrialization.

CHD individuals.

The association between values and attitudes towards life was studied in cross

It was found that Japanese who maintain their traditional way of life, values and language after their emigration to US, do not have increased rate of CHD. In study of Japanese- American males found that those with the lowest level of social affiliation had double the risk of developing CHD. The rate of CHD mortality increases due to smoking, alcohol and foods rich in fats, less exercise, lack of control over one's working environment, reduced levels of social support, the cumulative life cycle experience of belonging to a social class or nation undergoing rapid urbaniza-

The main objective of this research was to study the role of lifestyle in development of CHD and hypothesis formulated was patients of coronary heart disease (CHD) would score higher on subscales of lifestyle as compared to matched non-

This being a study on stress, anxiety, type A behaviour pattern and lifestyle variable of the patients of coronary heart disease (CHD) and their matched normal patients for the present study were selected from cardiac care unit (CCU) of hospitals from Pune city. During the survey for CHD patients 10:1 ratio of male to female was observed. As, there is a physiological cause that men having a greater risk of heart disease than women do, because, the higher levels of high density lipoprotein (HDL) cholesterol, which helps to slough off the more lethal low density lipoprotein (LDL), these higher HDL levels appear to be linked to premenopausal women's level of estrogen. Estrogen diminishes sympathetic nervous system arousal, which may add to protective effect against heart disease seen in women. So in the present study only male CHD patients were selected. Out of 121 male CHD patients admitted in CCU's of various hospitals in Pune, 81 CHD male patients agreed to participate in the present study. In the present study selection of 81 matched normal was done by keeping the patients in view. The patients and normals were matched, one to one on the variables of age, education, occupation, family type and socioeconomic status. These 81 male CHD patients met the inclusionary criteria, which were as follows: Age: 30–60 years; education: minimum S.S.C. passed; occupation: employed; family type: nuclear family is staying with wife and children, and joint family is staying with wife, children and parent; socioeconomic status: minimum income

**158**

Rs 10,000 per annum. The normals were selected after the medical checkup by the physicians who labeled them as normal as they were not suffering from any disease.

Following tools and measures we used for data collection.

Personal data sheet: A personal data sheet comprising 14 items was prepared and was required to be filled in by the patients and normal before the actual administration of psychological scales. The items were designed to get the information about age, education, occupation, family type and socioeconomic status.

Interview schedule: To measure lifestyle in CHD patients and normal individuals, structured interview schedule was prepared on the basis of operational definition of lifestyle. Interview schedule includes four subparts in which questions are formulated beforehand and asked in a set order in a specified manner. The description of interview schedule is given in Appendix A.

Description of the sub-dimensions is given below.


individual. Total eight questions were framed to get details about values of person out of which four questions were framed to get details about money and remaining four questions were framed to get details about religious values. A five point rating scale is used to measure the responses of the person. Higher the scores on money and religious value more risky lifestyle whereas lower scores indicate healthy lifestyle. Split half reliability was calculated and it is 0.89.
