CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 4, July/August 2022 AFRICA 213 significantly lower risk of diabetes compared to people born in Gauteng.155 Several studies have reported diabetes prevalence data on the > 50-year-old sample from the WHO-SAGE (wave 1) study, all of which describe its association with other diseases or risks. Quashie et al. (2019) reported a diabetes prevalence of 8.9% and showed that diabetes was associated with a four times greater odds of angina. Stubbs et al. (2018) reported a 9.2% diabetes prevalence when examining the association between multimorbidity and stress. Werfalli et al. (2018) also reported a diabetes prevalence of 9.2% and showed that the prevalence was higher in 60- to 69-year-olds (10.6%) compared to 50- to 59-yearolds (7.1%).63,171-173 Gender differences in the prevalence of diabetes have been reported by various studies in middle-aged men and women; however, the findings of these studies differ, with some showing a higher prevalence in women and others showing a higher prevalence in men. Using a FBG cut off of ≥ 7.0 mmol/l, Maimela et al. (2016) reported a higher prevalence in women compared to men between the ages of 45 and 54 years (9.1 vs 4.3%) and 55 to 64 years (15.7 vs 12.2%).26 The screening campaign by Peer et al. (2018) reported a prevalence of diabetes (known or RBG ≥ 11.1 mmol/l) in 13.8% in men and 12.8% in women, with age-specific prevalence also being higher in men than women (45–54 years: men 18.9% vs women 12.9%; 55–64 years: men 21.9% vs women 21.4%).28 As is recommended by various international diabetes organisations, the Society for Endocrinology, Metabolism and Diabetes of South Africa recommends a two-step targeted approach when screening for diabetes. This includes identifying individuals at high risk of diabetes: (1) individuals who are overweight with one or more risk factors for diabetes, such as physical inactivity, hypertension, family history of diabetes, dyslipidaemia, polycystic ovarian syndrome, high-risk ethnic group (South Asian descent), CVD history, gestational diabetes or baby > 4 kg, previous impaired fasting glycaemia or impaired glucose tolerance; or (2) adults ≥ 45 years old.174 This ensures more targeted screening for diabetes, which should ensure that the number of individuals with undiagnosed diabetes is reduced. This guideline highlights that the optimal management should focus on obtaining glycaemic control and reducing other risk factors for macro- and microvascular disease. It advises lifestyle modification and that physical activity is an important component if there are no contra-indications. Given the prevalence data available, which includes national and regional data highlighting populations most at risk, this section on diabetes should receive an A grading for the prevalence grading criteria (Table 3). However, a significant amount of work still needs to be done with regard to the development and implementation of policies for the management of diabetes in the South African population in order to reach the target outlined by the South African Strategic Plan. For this reason, the policy and implementation grade is a C (Table 3). Conclusion It is clear from this systematic review that prevalence data for this age group, both national and regional, is available, with some risk factors, such as obesity, hypertension and diabetes, having more extensive data than others, such as physical activity and diet. What is also evident is the disconnect between the availability of prevalence data, and the proposal and implementation of policies. This is not consistent across the risk factors, with some having higher grades for the availability of prevalence data for this age group, compared to the policy grading (physical activity, alcohol, obesity, hypertension and diabetes) and others having higher grades for policy and implementation compared to grades for prevalence data (tobacco, diet and dyslipidaemia). Perhaps lessons can be learnt and shared in order to achieve full marks for all the risk factors for both grades. Ensuring that harmonised methodologies are used to collect prevalence data for this age group in order to pool data and more clearly understand national and regional trends should be a priority in order to achieve an A prevalence grading for physical activity, tobacco, diet and dyslipidaemia, while some risk factors such as alcohol and diabetes have extensive prevalence data to draw on that can be used by government to prioritise and support the implementation of policies. The countdown to achieving SDG 3.4 by 2030 has begun.3 NCD Countdown 2075 collaborators, using cause-specific mortality data from countries that have committed to this goal, show that no country will achieve this by addressing a single disease, and that a combination of multimorbidity prevention strategies and strengthening the health system are necessary.175 Some high-income countries such as Denmark and New Zealand are on track to reach the SDG target if they maintain or improve the average rates of decline recorded between 2010 and 2016. While these countries focus on the traditional four-by-four approach, which is four major disease groups (cancer, CVD, type 2 diabetes and chronic respiratory disease) linked to four behavioural risk factors (insufficient physical activity, poor diet, tobacco use and harmful use of alcohol), it is now clear that this is a lot more complex in sub-Saharan Africa. The mismatch between local strategic NCD policy agendas that align with global recommendation, and the reality of the local NCD burden and its determinants in the region has meant that many strategic plans may not be effective in meeting their NCD goals. Dover and Lambert stress the importance of recognising the social, environmental, political and economic influences on health behaviours, and that policies and interventions must be designed around an understanding of individual, household and community factors that may influence these behaviours.176 This report card is the first of its kind and clearly describes what is currently known about the prevalence and policy implementation of eight important indicators of NCD risk. It very briefly summarises and grades the prevalence data available, and grades whether policies exist and whether they have been implemented. Future report cards will also include whether current targets set out by the Strategic Plan for the Prevention and Control of NCDs 2013–2017 have been met. We acknowledge Stacy Nelleman for completing the article screening for May 2018 and April 2019, and the librarians at the University of Cape Town Health Sciences Library. References 1. Gouda HN, Charlson F, Sorsdahl K, Ahmadzada S, Ferrari AJ, Erskine H, et al. Burden of non-communicable diseases in sub-Saharan Africa,
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