CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 4, July/August 2022 AFRICA 203 been shown to be effective. Each section then concludes with a grade and some recommendations. Results Several studies have made an important contribution to this literature, including the World Health Organisation’s Study on global AGEing and adult health (WHO-SAGE),14 the National Income Dynamics Study (NIDS)15 and the Prospective Urban Rural Epidemiology (PURE) study.16 WHO-SAGE is a multinational longitudinal study examining the health and wellbeing of adult populations. The study takes place in six LMICs (Mexico, Russia, India, Ghana, South Africa and China) with wave 1 having taken place in South Africa in 2007–2010, and subsequent waves in 2015–2016 (wave 2) and 2018–2019 (wave 3). Data have been collected in a nationally representative sample of over 50-year-old adults, with a smaller reference group aged 18–49 years, and the sample size for the South African cohort for wave 1 = 4 233, wave 2 = 4 085 and wave 3 = final numbers to be released.17 NIDS was the first national household panel study to be completed in South Africa, the first wave of which took place in 2008, with the last wave taking place in 2017. The core survey has been repeated every two to three years with a nationally representative sample of 28 000 individuals from 7 300 households. The PURE study is a large epidemiological study of approximately 225 000 individuals between the ages of 35 and 70 years (enrolled between 2003 and 2013) from urban and rural sites in 18 low-, middle- and high-income countries (South Africa, Tanzania, Zimbabwe, Bangladesh, Pakistan, Indian, occupied Palestinian territory, China, Colombia, Iran, Malaysia, Argentina, Turkey, Brazil, Poland, Chile, Saudi Arabia and United Arab Emirates). The aim of the PURE study was to examine the impact of urbanisation, modernisation and globalisation on health behaviours and the development of risk factors for cardiovascular disease (CVD) and NCDs, such as diabetes and cancer. Physical activity In 2010, the WHO published Global Recommendations on Physical Activity for Health, which detailed the science of primary prevention of NCDs through physical activity at the population level, and recommended that adults complete at least 150 minutes of moderate- to vigorous-intensity physical activity per week.18 Global estimates show that 27.5% of adults are insufficiently active, and that women are less active than men in most countries.19 Furthermore, physical inactivity has been shown to be responsible for 6% of deaths globally.20 The recently released WHO Guidelines on Physical Activity and Sedentary Behaviour for Children and Adolescents, Adults and Older Adults (2020) have included sedentary behaviour recommendations as well as specific sub-population guidelines, including for those with chronic conditions.21 Increasing the prevalence of people meeting physical activity recommendations by 10% is one of the 10 goals of the South African Strategic Plan for the Prevention and Control of NCDs.4 The SADHS 2003 reported a physical inactivity prevalence of 56% in men and 64% in women aged 45–54 years; and 67% in both men and women aged 55–64 years.13 Physical activity data were not reported in the 2016 SADHS,9 and while the SANHANES8 reports on cardiovascular fitness, physical activity is not included. Therefore, the only national data available report that physical inactivity prevalence is higher in women and increases with age. Twenty-three studies were selected for title and abstract screening. Of those, 10 studies reported data from WHO-SAGE, and five reported data from the PURE study. Nine of the 23 studies were excluded due to the age range of participants not falling within the selection criteria. Of the remaining 14 studies, a further seven were excluded due to one or more of the following: they did not report data by age group and therefore we could not extract data for the 45- to 65-year age group (n = 5); they reported on multi-country data and did not separate data by country (n = 2); or they did not report physical activity data and only used it as a covariate in analyses (n = 2). Therefore, this narrative discusses the data from the remaining seven studies.22-28 All studies reviewed, except two that included only women participants,22,23 and one that did not compare by gender,24 found that women were less likely than men to use active travel,25 were less physically active than men,25-28 and were therefore less likely to meet physical activity recommendations. Data from the Dikgale Health and Demographic Surveillance System (HDSS) site reported that the prevalence of physical inactivity was significantly higher in women compared to men (70.8 vs 40.7%, respectively),26 while differences between genders were around 10% in other studies.27,28 Furthermore, in all but one study,28 physical activity levels decreased with age. The prevalence of adults meeting physical activity guidelines across all the studies included in this review ranged from 34 to 75%, with the wide range possibly being attributable to the large variation in age and socio-economic variables. The WHO-SAGE study compared South African data to data from other LMICs (China, Ghana, India, Mexico and the Russian Federation) and found that South African participants (only data for participants over 50 years old included) had the highest prevalence of low physical activity (59.7%), while in the other countries, this ranged from 23 to 38%.25,27 Two studies found that a higher socioeconomic status was associated with lower ambulatory physical activity (walking).22,25 Furthermore, in various cross-sectional studies, physical activity was associated with lower fasting blood insulin and cholesterol levels,22 higher fat-free soft tissue mass,22 lower blood pressure and/or prevalence of hypertension,23,24,28 lower body mass index (BMI)25 and lower waist circumference.25 Five studies used self-reported questionnaires to assess physical activity, while two used objective measurements of physical activity.23,24 The two studies that employed objective measurements tended to show low participation in moderate- to vigorous-intensity physical activity (between two and 20% of the day), yet did not quantify adherence to WHO guidelines. The newly formed African Academic Consortium on Physical Activity for Health has recently released a number of policies in an attempt to reach the targets set out in the strategic plan, specifically focusing on guidance during the COVID-19 pandemic and beyond.29 Focus is placed on improving safety in order to allow for exercise for all, and on targeting and providing services at the individual, environmental and societal level. Furthermore, the Strategy for the Prevention and Control of Obesity in South Africa (2015–2020) has highlighted that the
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