CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 4, July/August 2022 AFRICA 209 Africans reported that adults with a low socio-economic status who were overweight/obese were more likely to be older (38.6%), women (84.9%), unemployed (82.9%), non-smokers (45.4%) and 51.0% of them used alcohol.121 The same study showed thar other social determinants of health within South Africa include neighbourhood safety, as it found perceived slow speed from traffic [odds ratio (OR) = 0.41; 95% CI: 0.23–0.72] to be associated with being less likely to be overweight/obese, and high crime during the day (OR = 2.20; 95% CI: 1.04–4.64) to be associated with overweight/obesity in women.121 Living in a household with greater resources or having a higher socioeconomic status in adulthood was significantly associated with obesity in women, while the same was not true for men, as reported by Case and Menendez.131 Findings from the 2016 SADHS report a range in the prevalence of overweight or obesity in adult women of different ethnicities, with the lowest prevalence in white women (67.4%) and the highest in Indian/Asian women (70%).9 In men, the prevalence of overweight or obesity was highest in self-identified white men (75%) and lowest in self-identified black African men (27%).130 It is widely accepted that obesity is a risk factor for cardiometabolic risk, and this has been shown by various studies in South African middle-aged adults.65,69,70,123,126 Data from a study in a self-identified urban black Free State community showed that overweight/obese adults older than 44 years had 25% greater risk of being hypertensive compared to adults with normal or underweight BMI. In order to identify South African men and women at risk of cardiometabolic diseases, Kruger et al. (2017) proposed new BMI cut-off points. These show that a cut-off point of 28 kg/m2 in women and 22 kg/m2 in men is associated with increased odds of various cardiometabolic risk outcomes, including elevated blood pressure, dyslipidaemia and type 2 diabetes.89 In an attempt to reduce the growing prevalence of obesity and raise awareness, the South African government adopted the 2015–2020 Strategy for the Prevention and Control of Obesity, introduced by the National Department of Health. This strategy recognises the need for a population-based approach to tackling obesity and acknowledges the importance of context and an enabling environment. It also emphasises the need to communicate with communities in order to educate and mobilise them.30 Given the current available evidence, a grade A is assigned to the availability of obesity data based on the prevalence grading criteria; however, grade B is assigned to policy and implementation as current policies have only been in place within the last 10 years (Table 3). Although national and regional evidence exists for this age group, it remains to be seen if the current policies will be effective in reducing obesity. Dyslipidaemia Raised cholesterol (total cholesterol > 5 mmol/l) is a major cause of CVD and disease burden in both high-income countries and LMICs.132 In 2016, the Global Burden of Disease study reported that high concentrations of total cholesterol caused 4.4 million deaths and over 93 million DALYs, representing the seventh and eight leading risk factors in terms of attributable DALYs globally for women and men, respectively.133 Furthermore, there has been a 15% increase in the deaths (either from ischaemic heart disease or stroke) due to high total cholesterol levels since 2006.133 Global targets to reduce the prevalence of dyslipidaemia are included in the WHO 25 × 25 goal (25% reduction in risk of premature death from NCDs by 2025) and focus on lowering total cholesterol levels to < 5 mmol/l and low-density lipoprotein (LDL) cholesterol to < 3 mmol/l.134 Although the Strategic Plan for the Prevention and Control of NCDs 2013–2017 adopted by South Africa aims to reduce premature mortality by 25% by 2020, it does not include a specific goal targeted at dyslipidaemia.4 In South Africa, it is estimated that since 2000, more than half of all ischaemic heart disease and more than one-quarter of all ischaemic stroke cases were associated with high serum cholesterol levels.38 Following international trends, the SADHS in 2003 reported that more than 5.7 million South Africans had an abnormal lipid profile, of whom less than 50% were on treatment.13 Self-reported high cholesterol levels among women aged over 15 years has increased from 1% (from SADHS 1998) to 4% in 2016 (SADHS 2016).9,135 In contrast, the SANHANES, completed in 2012, revealed that 28% of women and 19% of men older than 18 years had elevated total cholesterol levels, and 52 and 44% of men and women, respectively, had low levels of high-density lipoprotein (HDL) cholesterol.56 Although the national surveys reported the prevalence of abnormal lipid levels in South Africa, it was not specific to the 45- to 65-year age group, but rather included all adult ages from over 18 years. Dyslipidaemia is characterised by the presence of non-optimal levels of blood lipids. In clinical practice guidelines, dyslipidaemia is defined by elevated total cholesterol (> 5 mmol/l) and/or LDL cholesterol (> 3 mmol/l) levels. However, the definition is often extended to include non-optimal levels of HDL cholesterol (< 1.2 mmol/l ) and elevated circulating triglycerides (> 1.7 mmol/l).136 Of the 18 articles identified on dyslipidaemia, from the title and abstract screening, all were cross-sectional studies, including several articles from the PURE (n = 6)23,40,41,47,68,137 and regional studies (n = 12).26,67,69,76,78,122,123,138-142 Of the 18 studies, three reported limited information in the 45- to 65-year age group,67,122,139 while five studies were not designed to focus primarily on dyslipidaemia but rather to investigate various CVD risk factors in the broad adult population.41,47,68,76,137 This narrative therefore discusses the data from the remaining 10 studies. The prevalence of dyslipidaemia within middle-aged adults reported by various regional South African studies ranges from 31.7 to 67.3%.23,78,140,141 Dyslipidaemia affects both men and women; however, data from the CRIBSA and Dikgale HDSS studies show that lipid irregularities contributing to the overall diagnosis of dyslipidaemia differ between men and women.26,138 In the CRIBSA study, although the prevalence of high total cholesterol levels (> 5 mmol/l) was the same in men and women (38% for both), women had a higher prevalence of low HDL cholesterol (61.3 vs 55.7%) and high LDL cholesterol (62.5 vs 51.6%) compared to men in the 45- to 54-year age range.138 Furthermore, men had a higher prevalence of triglyceride levels > 1.5 mmol/l compared to women in the same age range (28.6 vs 19.0%). This differed from a study in Limpopo, where the 45- to 54-year-old women had a higher prevalence of high total cholesterol > 5 mmol/l (32.6 vs 21.7%) and raised triglyceride levels > 1.7 mmol/l (27.1 vs 21.7%) compared to men.26 When
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