CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 4, July/August 2022 208 AFRICA confirmed by data from a sample of South African households, which reported reductions in the sugar, calories and volume of SSB purchases with the implementation of the HPL.112 This is promising, as it supports both supply and demand level benefits of the HPL on SSB and added sugar consumption. However, data also suggested that the benefits of reduced SSB intake may be mitigated through high sugar consumption from other sources and that improving dietary patterns as a whole is critical to improving health outcomes. While national legislation and fiscal policies are important and documented progress is commendable, there is little evidence of progress on interventions, which would enable improved overall dietary patterns at a population level. This is important as targeting individual dietary components may have a limited impact on overall dietary patterns and, therefore, on obesity and NCD rates. It is increasingly being recognised that there is a need for changes to food environments that simultaneously stimulate demand for, and access to, healthier foods such as fruit and vegetables. Given the evidence currently available, a grade C is attributed to prevalence data for diet (Table 3). While regional data exist for the 45- to 65-year-old age group, more nationally representative data is needed. Specifically, routine monitoring of salt intakes at national and regional levels in this age group is necessary to track progress towards achieving the target of a 30% reduction in population salt/sodium intakes. In addition, data exploring dietary patterns, as well as their determinants, in this age group are needed to inform interventions and achieve progress towards other NCD targets, which are reliant at population-level dietary behavioural change. For policy and implementation, diet receives a grade A due to the number of national policies that have been implemented since 2003 (Table 3). In future, routine follow-up data to track effectiveness of these policies should be prioritised in order to build on and complement current initiatives. Obesity Obesity has become a global epidemic and amajor health challenge in both low- and high-income countries.113 Once associated with only developed countries, the prevalence of obesity, along with urbanisation and changes in lifestyle and environment, has increased rapidly in LMICs.114 According to the WHO global estimates, in 2014 more than 1.9 billion adults (39%) were overweight, of whom over 600 million (13%) were obese (BMI > 30.0 kg/m2).115 In the year 2019, it was reported that more than five million people died worldwide as a result of a high BMI.116 While being in line with the WHO’s Global Action Plan for the Prevention and Control of NCDs 2013–2020,53 the South African Strategic Plan targets a reduction in the prevalence of obesity by 10% by 2020.4 The first South African National Burden of Disease study ranked high BMI as the fifth highest risk factor for early death and years of life lived with disability,117 and national statistics reporting trends in the prevalence of overweight and obesity in South Africa between 1980 and 2014 showed that 64% of adult women and 30.7% of adult men were overweight or obese, with the numbers differing quite significantly between the ethnic groups.118 Currently, South Africa’s overweight and obesity prevalence is the highest in sub-Saharan Africa.119 Comparing cross-sectional data from a multi-country study, Ajayi et al. (2016) reported South Africa’s prevalence of obesity (54%) to be the highest compared to Nigeria, Tanzania and Uganda, with age being significantly associated with higher BMI.119 Obesity trends in South Africa have shown an increase between 2003 (SADHS) and 2012 (SANHANES), with the prevalence in women between the ages of 45 and 54 years increasing from 40 to 55%.120,121 The latest SADHS figures reported that the highest prevalence among women was between 45 and 64 years (81–82%), while the prevalence in men of this age group was 42.8% (45–54 years) and 53.2% (55–64 years).9 Forty-two studies were originally selected from the title and abstract search. Fifteen were excluded due to the age range of participants being outside the selection criteria (45–65 years) and because they reported pooled data from other countries. In addition, eight studies were excluded because obesity was not the outcome of interest examined and they did not include prevalence data. Data from the remaining 19 studies are discussed below.26,27,39,62,65,69–71,79,119,121–129 A study by Maimela et al. (2016), in a rural South African community found obesity to be highest in women between 45 and 64 years, with the prevalence showing an increasing trend from 13.6% in 15- to 25-year-olds to 41.9% in 55- to 64-year-olds, while being 45 years or older was associated with a twice as great risk of overweight/obesity among South African adults.26 In addition, as well as reporting age-standardised rates of overweight/obesity of 676 and 686 per 1 000 in adult men and women, respectively, the WHO-SAGE study reported that age was also associated with an increase in the prevalence of central obesity.124 The PURE study reported abdominal obesity in men (mean age 51.9 years) and women (mean age 51.8 years) and although there was no significant change in the rural men, central obesity increased in urban men from 6.1 to 11.7% over five years.71 Furthermore, at baseline, 63.6% of urban women were identified with abdominal obesity compared to 50.5% of rural women and this increased to 69.7% in urban and 55.1% in rural women at follow up.71 The gender difference in obesity prevalence in rural (27.8% women vs 10.6% men, p < 0.001) and urban (43.7% women vs 25.7% men, p < 0.001) South Africans between the ages of 45 and 65 years has been highlighted by several studies.26,69,123 In the study by Ajaya et al. (2016), the BMIs of the South African women were higher than those of the men. As a result, 60% of the women were obese, while only 33% of the men were obese.119 In addition, being a woman was associated with twice the odds of being obese [adjusted odds ratio (AOR) = 2.17; 95% confidence interval (CI): 1.19–4.00] compared with men.119 Although self-identified black South African women are the most affected by obesity, data from Soweto has shown that they are content with their body size or accepting of being obese, which is also aligned with what has been described as the preferred and/or ideal body size in several African populations.71,125 The SADHS 2016 report found that among women who perceived themselves as underweight or normal, 44 and 65%, respectively, were overweight or obese.130 Sociodemographic and socio-economic factors must be considered when trying to understand the aetiology of obesity in South Africa.39,71,79,130 Several studies have shown that living in an urban area, having a higher socio-economic status and being married or cohabiting (married under common law) were significant predictors of obesity in men, but not in women.30,39,71,79,130 However, another study among urban South
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