CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 4, July/August 2022 204 AFRICA high prevalence of physical inactivity in South Africa can be attributed to a lack of an inclusive environment and community networks, increased use of technology and time challenges.30 The International Society for Physical Activity and Health has recently released a call to action for policy makers globally, which includes eight areas for investment in order to boost physical activity.31 These include school programmes, active travel, active urban design, healthcare, public education and the media, sport and recreation for all, and workplace and community-wide programmes. Ultimately, in all cases a multisectoral approach to improving physical activity is required. Given the current available evidence, a grade B has been assigned to physical activity for the availability of prevalence data (Table 3). While national data are available, albeit between 2003 and 2012 only, there are few regional studies in this age group and not all data clearly define age group. Given the available data, it is unclear whether South Africa has reached the national target of increasing physical activity by 10% in 2020, as newer prevalence data do not exist, and previous national reports seem to show worsening of adherence to physical activity guidelines over time, rather than improvement. A grade C has been assigned for policy and implementation as the recent policy brief prepared by the African Physical Activity Network provides recommendations and an implementation framework aligned to the WHO Global Action Plan for Physical Activity, which is promising, although specific implementation plans for aging adults are not clear (Table 3). Alcohol consumption In 2016, the Global Burden of Disease (GBD) study estimated three million deaths [95% uncertainty intervals (UI) 2.6–3.6] and 131 (119.4–154.4) million disability-adjusted life-years (DALYs) were attributable to harmful alcohol consumption globally. It estimated harmful alcohol consumption to be the seventh leading risk factor for DALYs.32 In 2017, the global prevalence of harmful alcohol use was 6.4% for women and 18.5% for men.33 Data from sub-Saharan Africa report that alcohol was responsible for 6.4% of all deaths and 4.7% of all DALYs lost.34 There are a series of global initiatives focusing on alcohol consumption, including the WHO’s global strategy to reduce harmful alcohol use35 (targets contained within the NCDs global monitoring framework36) and alcohol use has been addressed in the sustainable development goals (SDG).3 The aims of these initiatives, as is the aim of the South African Strategic Plan for the Prevention and Control of NCDs,4 are to reduce harmful alcohol consumption by at least 10%. In 2000, the burden of disease and injury attributed to misuse of alcohol was 7.1% in South Africa, more than double that of the global mortality average, which was 3.2%.37,38 The 2016 SADHS reported that 10.5% of women between 45 and 54 years of age and 11.2% of women between 55 and 64 years of age consumed alcohol (drank alcohol in the last seven days before the survey) compared to 36.7 and 45.1% of men for the same age categories.9 It also reported that 4.4% of women and 27.8% of men between 45 and 54 years of age consumed five or more drinks on a single occasion in the 30 days prior to the survey (defined as risky drinking), and this decreased slightly in the older age group (55–64 years: 3.7% of women, 25.7% of men).9 The 2012 SANHANES did not report a prevalence of problem drinking in this age group,8 while the 2016 SADHS, using the CAGE test, reported problem drinking in approximately 15% of men and approximately 2.5% of women between the ages of 45 and 64 years.9 Data from the WHO-SAGE study (wave 1) reported a 3.7% prevalence of risky alcohol use, defined as heavy drinkers (more than drinks/week) and binge drinkers (more than three drinks/one occasion/week).39 Recent South African data published between 2013 and 2020 regarding alcohol consumption (n = 30) include national surveys (n = 8), regional studies (n = 7) and a global study (n = 1). Of these, 16 studies were excluded due to the lack of focus on alcohol consumption and/or prevalence. Therefore, 14 studies were included in this narrative. Self-reported alcohol use is the most common method of assessment due to the cost associated with measuring biological biomarkers;40 however, there are concerns with the accuracy of participants’ recall.41 Carbohydrate-deficient transferrin and gamma-glutamyltransferase are suitable biomarkers for identifying alcohol use or abuse in most populations as they are sensitive to high alcohol consumption; 41,42 however, these can be misinterpreted in patients with liver conditions.40,42 The definition of hazardous alcohol consumption may also result in differences in the reported prevalence between studies but is typically defined as a regular average consumption of 20 to 40 g of alcohol a day for women and 40 to 60 g a day for men. Data from the WHO-SAGE study (wave 1) reported that 13.7% of the 3 840 participants over 50 years of age were current users of alcohol, with the prevalence being higher in men compared to women (15 vs 6.9%).43 The Cardiovascular Risk in Black South Africans (CRIBSA) study reported an increase in self-reported alcohol use in both men and women over the age of 45 years between 1990 and 2008/2009, with the prevalence being significantly higher in men at both time points. The prevalence of problem drinking was also significantly higher in men than women in the age group 45 to 54 years (46.6 vs 16.2%) and 55 to 64 years (29.4 vs 15.8%).44 Data from the South African Panel Study of Small Business and Health, a longitudinal study conducted in African townships (n = 2 213), reported a prevalence of problem drinking in 14.5% of the sample over the age of 50 years, and a further 8.9% who reported problem drinking and daily tobacco use.45 Although there was an increase in problem drinking only from baseline to follow up at 12 months in the whole sample (19.6 to 21.1%), longitudinal data are not reported separately for those over 50 years of age. A study of farm workers in the Western Cape does not report current and problem drinking prevalences for the age group 45 to 65 years. However, their results show that this age group had Table 3. Grades for the major risk factors in South Africans Risk factor Prevalence data Policy and implementation Physical activity B C Alcohol consumption A C Tobacco use B A Diet C A Obesity A B Dyslipidaemia C B Hypertension A B Diabetes A C
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