CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 4, July/August 2022 206 AFRICA As members of a household, 45- to 64-year-old adults are likely to be exposed to second-hand smoke, with data from SANHANES reporting that more than half of this age group said that a member of their household smoked inside their homes.57 SANHANES data also reported that 35 to 41% of 45- to 64-year-olds were advised to quit smoking by a healthcare provider, and 49 to 52% of smokers tried to quit smoking.57 In addition, more than 80% of smokers aged 45 to 64 years acknowledged having read health warnings on tobacco packages, but only 47 to 56% of smokers then tried to quit smoking.57 Middle-aged adults are often the head of the household, and tobacco use may significantly reduce their household budgets for food, particularly healthy food.60 Given the evidence available and according to our grading criteria, a grade B is attributed to prevalence data on tobacco use (Table 3). While regular national surveys allow us to track national progress, published national and regional data are needed for the 45- to 65-year age group in order to identify geographical areas and communities needing attention. A grade A is attributed to policy and implementation as since the Tobacco Products Control Act in 1993, South Africa has continuously promulgated and implemented policies to reduce tobacco product consumption, which have proven successful (Table 3).85 To align with the WHO Framework Convention on Tobacco Control, which South Africa ratified in 2005,86 South Africa has committed to complete its legislation on tobacco by developing and implementing evidence-basedmeasures to regulatemarketing activities and sales reach, reduce the demand for tobacco, and provide alternatives to agricultural actors involved in the tobacco industry. Overall, the consistent use of WHO tools, indicators and definitions across surveys and studies for the reporting of tobacco use is key in order to track progress towards achieving a 30% reduction in the prevalence of tobacco users.36,82 Diet The WHO recognises diet as one of the key contributors to several major risk factors for NCDs.87 The diet-specific target for the Global NCD Action Plan and the Global Monitoring Framework for the prevention and control of NCDs is to achieve a 30% relative reduction in salt/sodium intake by the population by 2025.36,53 Alongside this, many of the other NCD targets rely heavily on substantial dietary behavioural change.36 In LMICs such as South Africa, rapid urbanisation and the transition to energy-dense diets high in saturated fat, sugar and salt, and low in micronutrients has been identified as a major driver of obesity and higher rates of NCDs.87 In South Africa, the Strategic Plan for the Prevention and Control of NCDs highlights the need for dietary change to tackle high obesity burdens and micronutrient deficiencies, with a specific focus on reducing the consumption of salt, fried foods and snacks, hard margarines, and sugary foods and beverages, while promoting consumption of whole grains, fruit, vegetables, legumes, lean meat and low-fat dairy products.4 In South Africa, data examining dietary intakes were predominantly from cross-sectional surveys, which used subjective recall-based dietary assessment tools (such as 24-hour recall and food-frequency questionnaires) to report on overall macro- and micronutrient intakes and/or intakes of specific dietary components or food items (e.g. salt intakes). This is an important point to be cognisant of when interpreting dietary data as these approaches may not account for the fact that individual dietary components are consumed in combination, within an overall diet.88 In addition, subjective dietary assessment tools have documented limitations related to the accuracy of portion-size estimation by participants, the varying contribution of individual food items to composite dishes, and the conversion of food items to their individual nutrient components, which may lead to inaccurate quantification of dietary intakes as well as under- and over-reporting, and must be considered when interpreting the dietary data reviewed.88,89 In addition, the adequacy or quality of dietary intakes is often assessed by comparing population mean or median energy, and macro- and micronutrient intakes with national or international guidelines. Since there are no guidelines specific to the South African population, studies most commonly use the USA’s Institute of Medicine’s dietary reference intakes (DRIs);90 however, other guidelines on specific nutrients are also used, for example, the WHO guidelines on added sugar or salt intake. This can add to the complexity of comparing and interpreting dietary intakes and adequacy across studies. Overall, 27 studies were identified in the review. However, nine studies were excluded due to the age range of participants being outside the selection criteria (45 to 65 years). In addition, three studies were excluded as they presented only pooled multi-country data: one was a methods article with no dietary data presented, one was a review, and one used dietary data in covariate analyses only. Data from the remaining 12 studies are therefore discussed below.27,28,39,91-99 These studies focused on two main areas: namely, (1) overall dietary intakes (macro- and micronutrients and/or food items/groups) and comparison with DRIs or recommendations where applicable; and (2) salt consumption. The results are, therefore, presented according to these categories. Dietary intakes and adequacy Macro- and micronutrient intakes of middle-aged men and women were reported in three cross-sectional studies. One included adults living in rural KwaZulu-Natal,92 one included urban adults from the CRIBSA study in the Western Cape,91 and the last involved secondary analysis of data from the PURE study.93 These studies showed that, in both the rural and urban settings, energy intakes were either close to, or in excess of, those recommended for middle-aged men and women.91-93 While only two of these studies assessed under- and over-reporting of dietary intake, only one subject was excluded as an ‘overreporter’ by Kolahdooz et al. (2013),92 and only ‘under-reporters’ were excluded by Steyn et al. (2016).91 One recent interventional study showed that women from peri-urban communities in the Free State consumed, on average, substantially lower (3 678–4 504 kJ per day) levels of energy than the estimated average requirement.94 This study also did not clarify whether under- and over-reporting were taken into account during their analyses. Three studies reported that, overall, carbohydrate intakes exceeded the recommended dietary allowance of < 130 g per day, while fibre intakes were low (< 25 g per day) and total or added sugar intakes were in excess of recommendations (> 25% and > 10% total energy, respectively).91,92,94 This suggests that middle-aged adults are likely to be consuming high amounts of refined carbohydrates,91,92,94 While the proportion of energy
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