2 Review of literature 4

Review of literature

2.1 Introduction ... ... ... ... ... ... ... ... 04

2.2 Non-communicable diseases (NCDs)... ... ... ... ... 05

2.3 Cardiovascular diseases (CVDs): Types, symptoms and risk factors 06

2.4 CVDs: Diagnosis and treatment ... ... ... ... ... 09

2.5 Burden of CVDs ... ... ... ... ... ... ... 09

2.6 Nutrition and CVDs ... ... ... ... ... ... ... 10

2.7 Future perspectives ... ... ... ... ... ... ... 14

2.1 Introduction

In the present era, the burden of communicable diseases is reducing and there is an
emergence of non-communicable disease epidemics (Patil, 2015). Tropical ailments like
malaria, cholera and many such diseases are declining where as there is a progressive rise in
occurrence of diseases like diabetes mellitus, chronic obstructive pulmonary disease,
cardiovascular disease and many more. The result of urbanization, modernization,
industrialization, increased life expectancy and the adaption of western lifestyle with reduced
physical activity or sedentary lifestyle and changes in dietary habits like increased intake of
refined, energy-dense fatty foods are the major risk factors for the development of non-
communicable diseases (Olawuyi and Adeoye, 2018). The burden of non-communicable
diseases (NCDs) are increasing in India due to changes in lifestyle of the population and most
burdens are attributed by cardiovascular diseases followed by respiratory diseases and other
NCDs (Sharma, 2015).

Cardiovascular diseases (CVDs) including coronary heart disease and stroke are the
most common non-communicable diseases found worldwide responsible for up to 17.8
million deaths in 2017 especially in low- and middle-income countries (Kaptoge et al., 2019).
 2 Review of literature 5

Several risk factors contribute towards development of cardiovascular diseases in developing

countries which includes high alcohol intake, smoking, high salt intake, diabetes, dietary
factors, high blood pressure, psychological factors like stress, anxiety and depression (Rehan
et al., 2016). Different diagnostic methods are used for the early diagnosis of CVDs; out of
them three-dimensional echocardiography, two-dimensional and three-dimensional speckle
tracking echocardiography are used as methods for detection of global and regional
myocardial dysfunction in various CVDs (Capotosto et al., 2018). The first step in prevention
of cardiovascular diseases is by helping people to modify their behavior (WHO, 2007).
Reducing smoking, body weight, blood pressure, blood cholesterol, blood glucose levels,
taking regular physical activities and eating healthy diet will promote health and reduce the
risk of CVDs. There are several evidences which show the links between many nutrients,
minerals, food groups and dietary pattern with an increased or decreased risk of CVDs
(Reddy and Katan, 2004). This short review aims to provide brief account on non-
communicable diseases, burden and risk factors of cardiovascular diseases, its diagnosis and
treatments as well as role of nutrition in progression and prevention of cardiovascular
diseases.

2.2 Non-communicable diseases (NCDs)

Non-communicable diseases (NCDs) are the leading cause of mortality throughout the
globe and are one of the major health challenges of the 21st century (WHO, 2018). Non-
communicable diseases such as cardiovascular diseases, cancer, chronic respiratory diseases
and diabetes are conditions of long duration and slow progression, having the most
significant impact on deaths worldwide (FIP, 2019). NCDs are driven by the effect of
globalization, rapid urbanization, trade of health-harming products and population growth.
The burden of NCDs is estimated to be one in five people having more than one chronic
condition in the western world. They are the result of a progressive effect of interaction
between various risk factors where no visible direct relationship can be established between
one single risk factor and the pathogenesis of disease (Patil, 2015). Therefore, it is very
important to identify and investigate the various risk factors responsible for the emergence of
the diseases. The effects of risk factors in the development of diseases are due to the result of
the interaction of the various risk factors to each other.

Almost all the countries are experiencing an increase in the NCDs, which affects all
age groups of both poor and rich people and men as well as women (Maimela et al., 2016).
 2 Review of literature 6

According to the WHO global status report on NCDs, about 38 million of mortality cases
were reported each year, more than 40% were premature and preventable (Kassa and Grace,
2019). Based on the WHO studies, by 2025 NCDs will account for above 70% of all deaths
worldwide, with 85% of these mortality cases occurring in developing countries. The NCDs
such as cancer, cardiovascular diseases, diabetes, chronic pulmonary diseases and mental
disorders are the major life threatening problems in industrialized countries (Boutayeb and
Boutayeb, 2005; Olawuyi and Adeoye, 2018).

Most of the NCDs share common risk factors, which mainly classified as behavioral
and biological risk factors (Maimela et al., 2016; Olawuyi and Adeoye, 2018). The
behavioural risk factors mainly includes tobacco use, intake of excess alcohol, consumption
of unhealthy diet or increased intake of energy-dense food and drastic decrease in physical
activity; while, the metabolic risk factors includes several health conditions such as high
blood pressure, overweight and obesity, hyperglycemia and hyperlipidemia. Along with
behavioural and metabolic risk factors, even the environmental risk factors like indoor and
outdoor air pollution, climate change, radiation, noise, exposure to toxic elements (like
copper, cadmium, lead, mercury and arsenic) and use of unsafe water affects individual’s
health (Norman et al., 2013; Patil, 2015; Chowdhury et al., 2018; Prüss-Ustün et al., 2019).
Along with above, the other risk factors such as elevated level of psychological stress,
emergence of other lifestyle related diseases, changed eating habits and increased use of
chemicals are also responsible for the development of body conditions like hypertension,
diabetes mellitus, cancer and many more such ailments. The major effect of NCDs is seen on
health of the individual and economic growth of the countries throughout the globe (UNSCN,
2018). Millions of people will experience premature death or compromised quality of life,
while countries and regions will experience reduced productivity and seized economic
growth. Increased prevalence of obesity, increased intake of poor quality diets and extensive
undernutrition are the major contributors for the development of NCDs. Presently, each and
every country throughout the globe bears a combined burden of malnutrition and NCDs.

2.3 Cardiovascular diseases (CVDs): Types, symptoms and risk factors

Cardiovascular diseases (CVDs) are one of the leading causes of disease burden,
mortality and morbidity throughout the globe especially in low-income and middle-income
countries (Prabhakaran et al., 2018a; Kaptoge et al., 2019). CVDs are group of diseases that
affects the heart and the circulatory system (Muhit et al., 2012; Labu et al., 2013; Amaravadi
 2 Review of literature 7

et al., 2018). It is mainly caused by the disorders of the heart and blood vessels and includes
ischemic heart disease, stroke, cardiomyopathy, congestive heart failure, peripheral arterial
disease, coronary heart disease, hypertension, rheumatic heart disease and many other cardiac
and vascular conditions which are the major contributor for the reduced quality of life as well
as leading cause of increased global mortality (Muhit et al., 2012; Rehan et al., 2016;
Amaravadi et al., 2018; Mensah et al., 2019). The possible risk factors for cardiovascular
diseases mainly includes sedentary lifestyle, hypertension, tobacco use, consumption of high
alcohol, increased low-density lipoprotein (LDL) cholesterol level, diabetes, anxiety, stress,
depression and other metabolic risk factors (Rehan et al., 2016; Shaima et al., 2016). Other
than these traditional risk factors, some non-traditional risk markers are also associated with
CVDs such as elevated homocysteine level, increased plasminogen activator inhibitor–1
(PAI-1) level, fibrinogen level, fibrin degradation marker, D- dimer level as well as level of
interleukin.

These different types of cardiovascular diseases are categorized based on the supply
of blood to different parts of the body or due to malformation of heart structure (Bhawana
and Neetu, 2015). They include;

Coronary heart disease: It is the disease of the blood vessels supplying the oxygenated blood
to the heart muscle (Bhawana and Neetu, 2015; Themistocleous et al., 2017). It is a condition
in which the walls of the arteries supplying blood to the coronary arteries become thickened
due to the development of lesions in the arterial wall, is called atherosclerosis (Frayn, 2005).
The lesions formed are called plaques. These plaques can restrict the supply of blood to the
myocardium (the heart muscle) and may lead to the development of chest pain on exertion
(angina) or breathlessness on exertion in the suffering individuals.

Cerebrovascular disease: It is the disease of the blood vessels supplying the brain and it
includes defined entities like stroke, transient ischemic attack and cerebrovascular
malformations (Frayn, 2005; Bhawana and Neetu, 2015; Onaolapo et al., 2019).
Hypertension, smoking, dyslipidemia, hyperlipidemia, atherosclerosis, small vessel disease,
migraine and hypertriglyceridemia were found to be the major risk factors for the
development of stroke in younger individuals. There are two types of stroke namely,
ischemic stroke and hemorrhagic stroke (Frayn, 2005). Ischemic stroke is due to blockage of
blood supply to the brain and it leads to irreversible damage to the brain tissues. The
hemorrhagic stroke is due the rupture of a blood vessel supplying the brain.
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Peripheral arterial disease: It is the disease of the blood vessels supplying the arms and legs
and is the major cardiovascular disease (Frayn, 2005; Bhawana and Neetu, 2015; Song et al.,
2019). Peripheral artery disease can be asymptomatic or symptomatic with several symptoms
like pain on exercise, intermittent claudication, atypical leg pain, critical limb ischaemia and
acute limb ischaemia. Advanced age, smoking, diabetes mellitus, family history and
dyslipidemia are the common risk factors for peripheral artery disease (Weragoda et al.,
2016).

Rheumatic heart disease (RHD): It is the damage to the heart muscle and heart valves from
rheumatic fever, caused by Group A Streptococcus bacteria that can be prevented and
controlled (Bhawana and Neetu, 2015; Venugopal and Gupta, 2018; Leal et al., 2019). RHD
leads to the damage of heart valves that occur after an episode of acute rheumatic fever.
Family history, Streptococcal bacteria, environmental factors such as unclean water,
improper sanitation, overcrowding, poor housing conditions, under nutrition are some of the
risk factors that leads to rheumatic heart disease.

Congenital heart disease: It is the malformations of heart structure existing at birth and
affects 6 to 8 babies in every 1000 live births (Blue et al., 2012; Bhawana and Neetu, 2015).
These malformations are due to the aberrant development of a normal structure in fetus or
failure of progress beyond the early stage of embryonic or early fetal development (Shetty et
al., 2017). Mother’s smoking was reported as one of the main dangerous risk factors for the
development of congenital heart disease in newborn infants (Naghavi-Behzad et al., 2013).

Deep vein thrombosis and pulmonary embolism: It is the blood clots in the leg veins, which
can dislodge and move to the heart and lungs (Bhawana and Neetu, 2015). The major
symptoms of deep vein thrombosis includes leg pain, swelling and in severe cases venous
ulcer (Stone et al., 2017). The risk factors for deep vein thrombosis or clot formation include
cancer, overweight and obesity, oral contraceptives and advancing age.

The coronary heart disease leads to heart attack as it reduces or completely cut off the
blood supply to the heart muscles due to thickening or hardening of the arteries results in the
death of heart cells and a heart attack occurs (Muhit et al., 2012). When the heart loses its
ability to pump blood efficiently leads to the development of a disorder known as congestive
heart failure. Many studies have confirmed the strong relationship between high blood
pressure and coronary heart disease (Shaima et al., 2016). Some studies reported that risk for
all forms of cardiovascular diseases increased significantly in the patients with type 1 and
 2 Review of literature 9

type 2 diabetes mellitus. The mortality rate was also found high in diabetic patients with
coronary heart disease compared to non-diabetic individuals.

2.4 CVDs: Diagnosis and treatment

Cardiovascular diseases (CVDs) are the leading cause of disability and mortality
throughout the world. Many diagnostic procedures ranging from non-invasive to invasive
testing are the valuable diagnostic tools for the cardiovascular system (Yousef et al., 2013).
These diagnostic procedures include blood tests and diagnostic imaging modalities (plain
film, cardiac catheterization, nuclear medicine, echocardiography, computed tomography
(CT) and magnetic resonance imaging (MRI)). There are countless cardiovascular disease
biomarkers are available and that have clinical use as diagnostic, prognostic and predictive
biomarkers (Dhingra and Vasan, 2017). Clinical history, physical examination, basic
evaluation like ECG, non-invasive imaging tests like MRI, CT coronary angiography is the
different methods used to diagnose chronic coronary heart disease (Albus et al., 2017). Minor
signs and symptoms of acute rheumatic fever are useful for diagnosis which includes fever,
general joint aches, blood tests and changes in echocardiogram (Venugopal and Gupta,
2018). The diagnosis of acute rheumatic fever which leads to rheumatic heart disease is based
on the diagnosis of rheumatic fever, presence of active vs. inactive rheumatic fever
recurrences, identification of carditis and valve damage in rheumatic heart disease.

The prevention of coronary heart disease and strokes starts with lifestyle advices
along with drug treatment (WHO, 2012). It includes termination of smoking, dietary changes
like reduced calorie intake and increased intake of fruits and vegetables (400 g/day), regular
light to moderate intensity physical activity, weight management and control and reduction of
alcohol consumption. Along with changes in lifestyle, several drugs such as antihypertensive
drugs, lipid lowering drugs, hypoglycemic drugs, antiplatelet drugs, anticoagulant treatment,
following myocardial infarction a beta blockers, vasodilators, ACE inhibitors, calcium
channel blockers, coronary revascularization and many more were suggested for the suffering
individuals (Psaty et al., 2003; WHO, 2012).

2.5 Burden of CVDs

Cardiovascular diseases are the most common non-communicable disease throughout

the globe responsible for up to 17.8 million deaths in the year 2017 (Kaptoge et al., 2019).
According to the Global Burden of Disease study age-standardized estimates in 2010, nearly
 2 Review of literature 10

a quarter (24.8%) of all deaths in India is attributable to CVDs (Prabhakaran et al., 2016).
About 83% of CVDs mortality in India is due to Ischemic Heart Disease (IHD) and stroke
with IHD being predominant. According to WHO, cardiovascular diseases caused about 30%
(17.5 million) of the 58 million deaths throughout the world and prevalence of coronary heart
disease was found high in urban population than rural population (7–13% vs. 2–7%)
(Krishnan, 2012). Even though the prevalence of CVDs risk factors are found high in urban
population, it is also increasing rapidly in rural population and is a serious threatening to the
Nation (Nag and Ghosh, 2013). A comparative study on trends in CVDs in India and United
States in 2016 reported that, there was an estimated 62.5 and 12.7 million years of life lost
prematurely due to CVDs in India and United States respectively (Prabhakaran et al., 2018b).
One more study on risk of cardiovascular diseases in female resulted that, coronary heart
disease and stroke were the major causes of death in women across the world including both
high-income and low-income countries (Woodward, 2019). The Global Burden of Diseases
study reported that age standardized CVDs mortality rate was found higher in India than the
global average (272 per 100,000 vs. 235 per 100,000 population) (Mishra and Monica, 2019).

Cardiovascular diseases affect the individual in their mid-life years and it also erodes
the foundation of socioeconomic development and also the families and Nation (Patil, 2015).
The increase in CVDs shows significant changes in the dietary habits, level of physical
activity and use of tobacco all over the globe as a result of industrialization, urbanization,
modernization, economic development and market globalization. Due to these there was
major changes in lifestyle of the people such as intake of unhealthy energy dense foods,
reduced physical activity and increased tobacco consumption. Unhealthy dietary pattern
included the increased intake of saturated fats, salts and refined carbohydrates as well as low
consumption of fruits and vegetables. These risk factors altogether lead to the development of
CVDs.

2.6 Nutrition and CVDs

Poor diet and other lifestyle related factors are the major risk factors for
cardiovascular diseases (Frayn, 2005; Bowen et al., 2018). Thus, effective nutritional
interventions along with promotion of smoke discontinuation and regular practice of aerobic
physical exercises are found to be major elements for prevention and regression of CVDs
(Ravera et al., 2016). Most of the recommended diet patterns for CVD prevention have
included reduction in total fat intake, which helps to reduce serum cholesterol level. Ample
 2 Review of literature 11

evidences are available which shows the link between several nutrients, minerals, food
groups and dietary pattern with an increased or decreased risk of CVDs (Reddy and Katan,
2004). The dietary fats like saturated fats and trans-fats are associated with increased risk of
coronary heart disease, while polyunsaturated fats are known to be protective. Increased
intake of dietary sodium is associated with hypertension, while potassium lowers the risk of
high blood pressure and stroke. Regular consumption of fruits and vegetables is protective
against high blood pressure, coronary heart disease and stroke, while the composite diets like
DASH diet, Mediterranean diet and prudent diet are associated with reduced risk of
hypertension and coronary heart disease. Along with above, high intake of fiber, antioxidants,
vitamins, minerals, polyphenols, mono- and polyunsaturated fatty acids, low intake of refined
sugar and carbohydrates also play a major role in prevention of CVDs (Casas et al., 2018).

Dietary fats

There is strong association between dietary fats and cardiovascular diseases,

especially coronary heart disease (Reddy and Katan, 2004). At first, this association was
considered to be mediated mainly through the atherogenic effects of different plasma lipids
like total cholesterol, lipoprotein fractions and triglycerides. The studies also reported that
specific dietary fatty acids play important roles in the cause and prevention of coronary heart
disease, but total fat content as percentage of energy is unimportant (Willett, 2012).
According to the classical lipid hypothesis, diet with high concentration of low-density
lipoprotein (LDL) cholesterol level leads to the development of coronary heart disease
(Virtanen et al., 2014). Cholesterol in blood and tissues are obtained from two sources such
as diet and endogenous synthesis (Reddy and Katan, 2004). Dairy fat and meat are the major
sources of cholesterol and even the egg yolk contains cholesterol but it does not provide
saturated fatty acids like meat and dairy products.

Fatty acids are categorized into three classes such as saturated fatty acids (SFAs),
monounsaturated fatty acids (MUFAs) and polyunsaturated fatty acids (PUFAs) (Reddy and
Katan, 2004). Saturated fatty acids and MUFAs are synthesized in the body, while
polyunsaturated fatty acids like n-6 and n-3 are called essential fatty acids as they cannot be
synthesized in the body.
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Saturated fatty acids and trans-fatty acids

High intake of dietary saturated fatty acids and trans-fatty acids in daily diet are
strongly correlated with elevated level of total and low-density lipoprotein (LDL) cholesterol
level in adults, which leads to the development of cardiovascular diseases (Morenga and
Montez, 2017). Saturated fatty acids as a group give raise to total and LDL cholesterol level,
but the individual SFAs have different effects (Reddy and Katan, 2004). There are three types
of saturated fatty acids like short, medium and long chain SFAs (Briggs et al., 2017).
According to Nurse Health Study, consumption of short and medium chained SFAs was not
associated with increased risk of coronary heart disease, while intake of long chain SFAs
increased the risk. Lauric acid increases LDL cholesterol level as well as raises the high
density lipoprotein (HDL) cholesterol level, thus it decreases the total cholesterol: HDL
cholesterol ratio. The most common long chain saturated fatty acids are myristic acid,
palmitic acid and stearic acid. Myristic and palmitic acid showed similar effect as lauric acid,
while stearic acid showed neutral effect (Reddy and Katan, 2004; Briggs et al., 2017;
Praagman et al., 2019).

Trans-fatty acids are the isomers of unsaturated fatty acids produced by

hydrogenation of unsaturated oils or by biohydrogenation in the stomach of the ruminant
animals (Reddy and Katan, 2004; Iqbal, 2014). High contents of trans-fatty acids are seen in
Vanaspati ghee and margarine. Consumption of high amount of trans-fatty acid is directly
associated with increased risk of cardiovascular diseases as it increases the LDL cholesterol
to HDL cholesterol ratio. The most common industrially produced trans-fatty acids in the
food supply are eliadic acid isomers, while ruminant derived trans-fatty acid is vaccenic acid
and conjugated linolenic acid (Iqbal, 2014; Souza et al., 2015). Ruminant derived trans-fatty
acids are seen in dairy products and meat of ruminant animals and are naturally occurring
trans-fatty acids (Iqbal, 2014; Souza et al., 2015; Islam et al., 2019). The industrial trans-fatty
acids have shown increased risk of CVDs than natural ruminant derived trans-fatty acids.

Monounsaturated fatty acids

The most important and only nutritionally important monounsaturated fatty acid
(MUFAs) is oleic acid, which found highly in olive oil, canola oil and also in nuts (Reddy
and Katan, 2004). Consumption of MUFA rich diet showed decrease in blood glucose,
triglyceride and LDL level and on the other hand increase in HDL cholesterol level
(Schwingshackl and Hoffmann, 2012).
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Polyunsaturated fatty acids

Polyunsaturated fatty acids (PUFAs) mainly include omega-3 and omega-6 fatty acids
(Maki et al., 2018). The marine based omega-3 PUFAs like ecosapentanoic acid and
docosahexaenoic acid possess a variety of cardio protective effects which includes effects on
blood lipids, oxidative stress, hemodynamics and markers of inflammation. The omega-3
fatty acid (alpha-linolenic acid) and omega-6 fatty acid (linoleic acid) are essential fatty acids
as they cannot be synthesized by the body, thus it must be supplied through diet especially
through plant sources like flaxseeds, walnuts, soybean oil, sunflower oil, linseed oil, fish oil,
oily fish, certain seaweeds, peanuts, eggs, cottonseed oil, corn oil and canola oil (Reddy and
Katan, 2004; Johnson and Bradford, 2014; Bowen et al., 2016; Maki et al., 2018).

The replacement of saturated fats and trans-fatty acids in the diet by increasing the
consumption of foods containing mono- and poly-unsaturated fatty acids will decrease the
dietary low-density lipoprotein (LDL) cholesterol level and also reduce the risk of
cardiovascular diseases (Reddy and Katan, 2004; Souza et al., 2015; Sacks et al., 2017).

Carbohydrates

In the recent years, the attention has been switched from saturated fats to
carbohydrates as high carbohydrate intake along with high glycemic index or glycemic load
diets is strongly associated with cardiovascular diseases (Pan et al., 2018; Brandhorst and
Longo, 2019). The relationship between carbohydrates and cardiovascular diseases is through
indirect mechanisms like contribution to total energy and its effect on overweight, obesity,
influence on central obesity and effect on plasma lipids (Reddy and Katan, 2004; Brandhorst
and Longo, 2019). The consumption of higher dietary fibre is associated with reduced risk of
CVDs. High carbohydrate diet reduces high-density lipoprotein (HDL) cholesterol level and
increases the fraction of small dense low-density lipoprotein (LDL) level which leads to
vascular diseases.

Dietary fibre

Dietary fibre is a heterogeneous mixture of indigestible carbohydrates or

polysaccharide and lignin which are found in plants that cannot be degraded by the
endogenous enzyme of the vertebrate animals (Reddy and Katan, 2004; Salas-Salvadó et al.,
2006). There are two types of dietary fibre, categorized based on their physical behaviour in
water such as insoluble fibre (cellulose, lignin and some hemicellulose found in wholegrain
 2 Review of literature 14

cereals) and soluble fibre (gums, mucilage and pectin found in fresh vegetables, fruits and
legumes as well as beta-glucans found in oats, barley and some yeasts). Consumption of
dietary fibre is strongly associated with incidence of cardiovascular diseases especially
coronary heart disease. Several epidemiological studies reported that addition of 10g of fibre
to the diet decreased up to 17% of coronary heart disease risk. The dietary fibre also shows
cholesterol lowering effects such as the consumption of fermentable fibre like pectin,
psyllium, glucomannan and guar gum remarkably decreased the serum total cholesterol and
LDL-cholesterol levels in the body (Sánchez-Muniz, 2012).

Antioxidants

Oxidative stress is the major reason for the development of cardiovascular diseases
and most of these conditions like hypertension, ischemia, heart failure, infarction mediated
cell growth, atherosclerosis and hyperlipidemia are developed due to disturbed cellular redox
state (Jain et al., 2015). Antioxidants directly scavenge the free radicals or reactive oxygen
species, thus increased dietary intake or supplementation of these nutrients will be helpful to
prevent atherosclerosis as well as other vascular diseases (Reddy and Katan, 2004).
Phytochemicals are the plant secondary metabolites which play a major role in prevention of
several chronic diseases. So far, about 10,000 phytochemicals have been identified which
includes tannins, flavones, triterpenoids, steroids, saponins and alkaloids which shows
protective role against pathogenesis of many chronic disorders (Zang et al., 2015).
Flavonoids, several antioxidant polyphenols, lycopene, carotenoids and many more
components shows protective activities for CVDs like blood pressure reduction,
atheroprotective effects, inhibitory effects on human platelet aggregation and many more.

2.7 Future perspectives

Cardiovascular diseases (CVDs) are one of the leading causes of mortality and
morbidity in India. The development of CVDs may be due to changes in lifestyle,
urbanization, modernization and industrialization. This change includes use of tobacco,
changes in diet habits of the individual and sedentary lifestyle. Due to the development in the
medical field several new diagnostic techniques and treatment methods are developed to
tackle the risk of cardiovascular diseases and to increase the quality of life of the individual.
The hospitals also suggest and provide the therapeutic diets which helps in the early recovery
of the patients. Thus, it is necessary to know the prevalence, real causes and risk factors for
 2 Review of literature 15

cardiovascular diseases in and around us and it is also necessary to understand the correlation
of CVDs with socio-demographic variables as well as other non-communicable diseases.