CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 4, July/August 2022 AFRICA 201 The unforeseen arrival of the COVID-19 pandemic in South Africa in 2020 has highlighted the risk of NCDs, particularly in settings with high social and economic inequality. One in five people who become infected with COVID-19 are at an increased risk of hospitalisation and mortality, largely as a result of underlying NCDs.6 Furthermore, the restrictions that have been implemented in order to reduce the spread of COVID19 have implications for health behaviours that are directly associated with NCD risk, such as diet and physical activity. The interruption of NCD services, as well as public health and surveillance activities, add to the challenge of this pandemic, but the response by governments in rapidly urbanising cities in low- and middle-income countries (LMICs) may also provide opportunities for whole-of-society approaches that can be employed to improve health.7 Data from two recent national surveys have shown that middleaged adults (45–65 years) are at highest risk for many of the NCD risk factors.8,9 Within the life course, middle adulthood is critical, as individuals in this age group are still working and contributing to the economy and society, and in many cases, particularly in LMICs, are also supporting the extended family.10 Healthy aging needs to be prioritised to not only ensure an optimal quality of life, but also to minimise the strain on the health system. The Healthy Aging Adult South Africa (HAASA) report card provides a systematic review of evidence on middle-aged South African adults (45–65 years), published between 2013 and 2020 on diet, physical activity, tobacco and alcohol use, obesity, hypertension, dyslipidaemia and diabetes. Only national and regional prevalence data are reported and data were included when (1) the mean age was between 45 and 65 years; or (2) the majority of participants were between these ages; or (3) if age-specific data between 45 and 65 years were reported. Each of the risk factors reviewed in the sections below have been assigned a grade based on the availability of data and whether national policies have been proposed and implemented. A similar grading system to the Healthy Active Kids South Africa (HAKSA) report card was utilised,11 and the criteria presented in Table 1 were employed. Methods This review was registered in the PROSPERO registry for systematic reviews (registration number: CRD42018093064) and was conducted in accordance with the PRISMA guidelines (see Fig. 1).12 The search for articles was conducted in May 2018 and then again in April 2019 and May 2020, according to the participants, intervention, comparator and outcomes (PICO) model of formulating a clinical question in the healthcare setting. Restrictions to articles were based on age of participants (between 45 and 65 years), study population (South African) and date of publication (from 1 January 2013 until 30 May 2020). The following databases were used in the search: PubMed, Scopus, Web of Science, EBSCOhost (including Africa Wide, CINHAL, academic search premier and health source). A sample of the PubMed search strategy is available as Table 2. Meta-analyses, systematic reviews, randomised control trials, cohort studies, case studies, longitudinal and cross-sectional studies, were included. Animal and genetic studies as well as studies not written in English were excluded. The results were screened and duplicates were removed, followed by title and abstract screening. After the first search in May 2018, full-text screening was completed by a research assistant who excluded 185 of the 284 full texts (Fig. 1). For the second and third searches in April 2019 and May 2020, respectively, a total of 588 titles and abstracts were screened Table 1. Criteria used to grade each risk factor Grade Prevalence data Policy and implementation A Published national and regional prevalence data available for this age group National policy/ies have been implemented for more than 10 years B Published national and regional prevalence data available, not specific to age group National policy/ies have been recently (less than 10 years) implemented C Only regional prevalence data for this age group National policy/ies have been proposed but not implemented D Only regional prevalence data but not specific to this age group No national policy/ies E No prevalence data Fig. 1. PRISMA flow diagram
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