CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 4, July/August 2022 210 AFRICA comparing the two age groups (45–54 vs 55–64 years) in the CRIBSA study, Peer et al., (2014) observed a decrease in the prevalence of high total cholesterol (38–26%), low HDL cholesterol (55.7–55.5%), high LDL cholesterol (51.6–31.1%) and high triglycerides (28.6–26.6%) with age in men; while an increase in all lipid indicators was observed in women: high total cholesterol (38.9– 45.8%), high LDL cholesterol (62.5–66.1%) and high triglycerides (19–25.1%).138 In contrast, the Dikgale HDSS data observed a 7.1% decrease in men and a 15.5% decrease in women in the prevalence of high total cholesterol levels in the 55- to 64-year group compared to the 45- to 54-year group.26 Therefore, dyslipidaemia appears to affect middle-aged men and women differently. Although the prevalence of dyslipidaemia in men and women differs across regions in South Africa, the same factors are strongly associated with dyslipidaemia in both genders, including age, overweight or obesity and waist circumference.23,26,78,138,140,141 In addition to observed gender differences in the prevalence of dyslipidaemia, ethnic differences are evident within South Africa. A regional cross-sectional study showed that selfidentified black African men and women were less likely to have hypercholesterolaemia compared to their self-identified white counterparts (men, OR: 0.64, 95% CI: 0.49–0.84; women, OR: 0.52, 95% CI: 0.43–0.62).123 In addition, self-identified Indian men were more likely to have hypercholesterolaemia than white men (OR: 1.47, 95% CI: 1.05–2.08).123 A general linear pattern was observed for the association between hypercholesterolaemia and BMI category in self-identified black Africans and selfidentified white participants, while no discernible pattern in self-identified Indian or self-identified coloured participants was found. Compared with normal-weight participants, the odds for hypercholesterolaemia were significant for overweight self-identified white participants (OR: 1.51, 95% CI: 1.18–1.94), and obese self-identified white participants (OR: 1.55, 95% CI: 1.19–2.03) and self-identified black Africans (OR: 1.63, 95% CI: 1.25–2.12).123 Of particular concern when reviewing this literature and highlighted by data from the Health and Aging in Africa Longitudinal study (HAALSI) in Agincourt, Mpumalanga, is that only a small proportion of individuals (1.05%) were aware of their dyslipidaemic condition and, of those who were aware, less than 1% (0.73%) are currently on treatment.141 The WHO has reported that a 10% reduction in serum cholesterol level in men aged 40 years and over is associated with a 50% reduction in heart disease within five years.132 Low-cost methods for identifying at-risk individuals exist and treatment with cholesterol-lowering medications in the form of statins is cost effective and is known to have a positive effect. The most recent content review by the Heart and Stroke Foundation South Africa in 2017143 confirmed the current guidelines from the 2016 European Society of Cardiology and European Atherosclerosis Society Guidelines for the Management of Dyslipidaemia, in which the desired lipid targets are a total cholesterol level < 5 mmol/l; LDL cholesterol < 3 mmol/l; HDL cholesterol > 1.2 mmol/l for women and > 1.0 mmol/l for men, and a fasting triglyceride level < 1.7 mmol/l. Given the current evidence available and according to our prevalence and policy and implementation grading criteria, a grade C and B are attributed to dyslipidaemia, respectively (Table 3). More recent published national data are needed (particularly for the 45- to 65-year age group) in order to highlight the prevalence of dyslipidaemia in middle-aged South African adults, and the consequences thereof. Current guidelines for the management of dyslipidaemia have been updated and currently implemented since 2017, however, regional studies have shown that regardless of this, less than 1% are currently on treatment. Hypertension In 2019, the Global Burden of Disease Study estimated that high systolic blood pressure (SBP > 140 mmHg) resulted in approximately 10.8 million deaths globally. However, this estimate excludes individuals with hypertension through elevated diastolic pressure or who are on antihypertensive treatment with an SBP of less than 140 mmHg.116 In 2015, the WHO estimated that the total number of individuals living with hypertension was 1.13 billion, two-thirds of whom lived in LMICs.144 This is of great concern as awareness, treatment and control remain problematic in these regions.145,146 As part of the WHO 25 × 25 target, the United Nations set a target for 25% reduction in the prevalence of SBP > 140 mmHg between 2010 and 2025.147 The South African target as part of the Strategic Plan for the Prevention and Control of NCDs 2013–2017 adopted the broader definition of hypertension, setting a goal of 20% reduction in the prevalence of raised blood pressure by 2020 (by medication and lifestyle), and a 30% increase in individuals controlled for hypertension.4 South African blood pressure data from the Global Burden of Disease study (2015, n = 13 580) showed a > 60% increase in estimated death and disability due to elevated blood pressure between 1990 and 2015.148 Across these 25 years, SBP increased in both men and women and across all older age groups (45–49, 50–54, 55–59 and 60–64 years). Hypertension is most commonly classified as SBP of 140 mmHg or above, and/or diastolic blood pressure (DBP) of 90 mmHg or above, and/or on hypertension medication. Of 58 articles identified from the title and abstract screening, 18 presented data on hypertension prevalence specifically for South African adults, with results presented for age groups within the 45- to 64-year age range.26-28,43,61,64, 65,148-158 Reasons for exclusion of articles were: hypertension data were combined across countries (n = 5), data were not presented by age group within the target age range (n = 33), or data were presented from selected groups, such as teachers or adults with normal blood pressure only (n = 2). With the exception of the WHO-SAGE study, which used wrist blood pressure measurement, most other studies presented blood pressure data from automated measurements taken at the brachial artery. The majority of articles reported conducting three measures and blood pressure data were most commonly presented as the average of the second and third readings. However, several studies used methods that could potentially lead to over- or underestimates of blood pressure or hypertension prevalence (averaging all blood pressure measurements taken, using the highest or lowest blood pressure value recorded, or using self-reported data only on hypertension status). A report produced by the Health Systems Trust in 2015 compares the NIDS hypertension prevalence data between 2008 and 2012, showing that hypertension prevalence remained fairly static in this time period,159 although prevalence had increased since the 1998 SADHS survey.135 However, the 2016 SADHS data9 report that hypertension prevalence overall has nearly
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