Kerala CADI

CADI Kerala

  • In Kerala, the health indicators such as high life expectancy, high literacy (89%), very low fertility rate, a reasonably good health care system match closely with the developed countries. Life expectancy─ one of the best measures of socio-economic progress (because it captures improvements in living standards, healthcare, safety, nutrition, and environmental protection), was only 34 years in the Stone Age. Kerala has the highest life expectancy in India ─ 75yrs ─ 11 years higher than the national average of 64 years, and just 3 years shy of 78 years in the US.
  • Naturally one would expect a lower prevalence of heart disease in Kerala. Nonetheless, lifestyle diseases ─ heart disease, diabetes, high blood pressure, and obesity ─ are paradoxically high and result in very high mortality and morbidity from malignant heart disease. (see Kerala Paradox)
  • The age-adjusted CAD (coronary artery disease) mortality rates per 100,000 are 382 for men and 128 for women in Kerala.1 These CAD rates in Kerala are higher than those of industrialized countries and 3 to 6 times higher than Japanese and rural Chinese (Figure 032).1
  • CAD in Kerala is premature and malignant resulting in death at a very young age. Approximately 60% of CAD deaths in men and 40% of CAD deaths in women occur before the age of 65 years.1
  • The extremely high mortality from malignant CAD in Keralans can be better appreciated when comparing with the rates in United States where only 18% of the CAD death occur in people younger than 65 years.2   The CAD death rates in Kerala are also higher than that of rural Andhra Pradesh and similar to urban Chennai.3 4
  • The average age of a first heart attack decreased by at least 10 years in Kerala, in sharp contrast to a 20 year increase in many western countries.5, 6 In the 1960s and 70s, heart attack in the very young (before the age of 40) was very uncommon in Kerala. Heart attack rate among men in this age group increased 40-fold by 1990 with at least 20% heart attacks occurring before age 40 and 50% before age 50.7-9
  • The high rates of premature heart disease in Kerala also results in a high economic burden as high as 20% of its state domestic product.10 Hospitalization for a heart attack results in catastrophic health spending in more than 60% of the high income and more than 80% of low income Keralans with 50 % of these requiring distress financing.11
  • Prevalence of heart disease in rural Kerala is 7%, which is nearly double that of north India and parallel the high levels of cholesterol in Kerala ─ the state named after the ubiquitous coconut.12, 13
  • The prevalence of risk factors is high even in rural Kerala: diabetes 20%, high blood pressure 42%, high cholesterol (>200mg/dl) 72%, smoking (42% in men) and obesity (body mass index >25) 40%, physical inactivity 41%, unhealthy alcohol consumption 13%.1, 13-15 (see Kerala Risk Factors)
  • The dramatic increase in premature CAD in Kerala is due to a corresponding increase in the modifiable risk factors related to lifestyle at a young age.16-19 The contributing factors include unhealthy diet, sedentary lifestyle, high consumption of alcohol, lack of physical activity, and air-pollution, along with very high intake of saturated fat as part and parcel of cultural norm dating back to several millennia.17
  • Kerala’s current situation can be considered a harbinger of what is bound to happen in the future to the rest of India.15  The knowledge base to drastically reduce the burden of CAD through lifestyle and medications exists as evidenced by the unequivocal demonstration of a 70% decline of CAD in the US and 80% in Finland over the past 3 decades. Unfortunately such measures are not occurring in Kerala or in other states of India where CAD and other non communicable diseases are rising at a faster pace than anywhere else in the world.15


1. Soman C. R, Kutty VR, Safraj S, Vijayakumar K, Rajamohanan K, Ajayan K. All-Cause Mortality and Cardiovascular Mortality in Kerala State of India: Results From a 5-Year Follow-up of 161 942 Rural Community Dwelling Adults. Asia Pac J Public Health. May 10 2010.

2. American Heart Association Heart and Stroke Statistical Update2010.

3. Joshi R, Chow CK, Raju PK, et al. Fatal and nonfatal cardiovascular disease and the use of therapies for secondary prevention in a rural region of India. Circulation. Apr 14 2009;119(14):1950-1955.

4. Gajalakshmi V, Peto R. Verbal autopsy of 80,000 adult deaths in Tamilnadu, South India. BMC Public Health. Oct 15 2004;4:47.

5. Mammi MV, Pavithran K, Abdu Rahiman P, Pisharody R, Sugathan K. Acute myocardial infarction in north Kerala–a 20 year hospital based study. Indian heart journal. 1991;43(2):93-96.

6. Pyorala K, Palomaki P, Miettinen H, Mustaniemi H, Salomaa V, Valkonen T. Decline in coronary heart disease mortality in Finland: Effect of age and gender distribution on the disease. Am. J. Ger. Cardiol. 1994;May/June:20-32.

7. Girija G. Risk factor profile of patients with acute MI. In: Vijayaraghavan G, ed. Cardiovascular Disease Prevention: Trivandrum; 1996:78 – 83.

8. Bahuleyan CG. Hospital data on coronary heart disease from North Kerala. In: Vijayaraghavan G, ed. Cardiovascular Disease Prevention: Trivandrum Medical College; 1996:54-59.

9. Enas EA. How to Beat the Heart Disease Epidemic among South Asians: A Prevention and Management Guide for Asian Indians and their Doctors. Downers Grove: Advanced Heart Lipid Clinic; 2005.

10. Mahal A, Karan A, Engelgau MM. The Economic Implications of Non-Communicable Disease for India: avaible at WWW.World Bank/documents and reports. Accessed  November 1, 2010;2010.

11. Huffman M D, Rao KD, Pichon-Riviere A, et al. A cross-sectional study of the microeconomic impact of cardiovascular disease hospitalization in four low- and middle-income countries. PLoS ONE. 2011;6(6):e20821.

12. Kutty VR, Balakrishnan KG, Jayasree AK, Thomas J. Prevalence of coronary heart disease in the rural population of Thiruvananthapuram district, Kerala, India. Int J Cardiol. 1993;39(1):59-70.

13. Joseph A, Kutty VR, Soman CR. High risk for coronary heart disease in Thiruvananthapuram City: A study of serum lipids and other risk factors. Indian heart journal. 2000;52(1):29-35.

14. Soman CR, Shahulhameed S, Ramankutty V, et al. Cohort Profile: The PROLIFE study in Kerala, India. Int J Epidemiol. Sep 8 2009.

15. Thankappan K R, Shah B, Mathur P, et al. Risk factor profile for chronic non-communicable diseases: results of a community-based study in Kerala, India. Indian J Med Res. Jan 2010;131:53-63.

16. Gupta R, Misra A, Pais P, Rastogi P, Gupta VP. Correlation of regional cardiovascular disease mortality in India with lifestyle and nutritional factors. Int J Cardiol. Apr 14 2006;108(3):291-300.

17. Sugathan TN, Soman CR, Sankaranarayanan K. Behavioural risk factors for non communicable diseases among adults in Kerala, India. Indian J Med Res. Jun 2008;127(6):555-563.

18. Kaur P, Rao T. Prevalence of cardiovacular trisk factors in an urban industrial population in South india. JAPI. 2007;55:771-776.

19. Mohan V, Deepa M, Farooq S, Prabhakaran D, Reddy KS. Surveillance for risk factors of cardiovascular disease among an industrial population in southern India. Natl Med J India. Jan-Feb 2008;21(1):8-13.

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