CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 4, July/August 2022 168 AFRICA common among men than women, with some studies reporting problem drinking rates (as assessed by the CAGE questionnaire) of close to 50% in men. As almost all studies rely on self-reported alcohol use and not on biomarkers, it is likely that the rates of alcohol use and misuse are even higher than those reported. Obesity, hypertension and diabetes can be quantified relatively easily, and these risk factors are therefore included in multiple population surveys. South Africa has not escaped the international epidemic of obesity and we have very high and increasing rates of obesity. When it comes to obesity, women are much more affected than men in South Africa, with rates of female obesity being twice or three times those of male obesity. There are also significant differences by ethnicity, with selfidentified Indian and black women having the highest rates of obesity, with the lowest rates found in black African men. The prevalence of diabetes increases with age and body mass index. The reported prevalence varies significantly by assessment method, generally being lowest for self-reported diabetes and highest for glycated haemoglobin (HbA1c)-based screening. There does not seem to be a clear gender bias, with some studies reporting higher prevalence in males while other studies show the reverse. However, there are consistent differences by ethnicity with Indians, blacks, and mixed-ancestry (coloured) South Africans having significantly higher rates of diabetes than white South Africans. The prevalence of hypertension increases markedly with age, with around 50% of 45–54-year-old persons being hypertensive, while the prevalence is around 75% in those 55–65 years old. Less than half of hypertensive patients are aware of their diagnosis, not all patients with a diagnosis of hypertension are receiving treatment, and in those on treatment, four out of five have uncontrolled hypertension. Dyslipidaemia is diagnosed and treated adequately in even fewer patients. Prevalence data for tobacco use and physical activity is graded B (published national and regional prevalence data available, not specific to the 45–65-year age group). Not unexpectedly, the rates of physical inactivity are high, with most studies showing women to be more inactive than men. Smoking rates are also worryingly high with all studies consistently showing higher smoking rates in men. The data for diet and dyslipidaemia is graded C (only regional prevalence data for the 45–65-year age group). Most of the dietary data is based on food recall and is therefore subject to recall inaccuracies as well as over and under reporting. Although there are significant differences in the macronutrient composition and micronutrient content of the diets reported by various studies, a common theme is a high intake of processed foods, simple carbohydrates, sugar and salt. The picture painted is therefore not rosy. For many and complex reasons, including poverty, social deprivation, slick advertising and the convenience of ready-to-go, processed foods, unhealthy lifestyles are widespread in South Africa. These unhealthy behaviours such as lack of physical activity, smoking, poor diet and alcohol misuse contribute to the development of physiological risk factors such as obesity, hypertension, dyslipidaemia and diabetes. The high rates of cardiovascular disease in South Africa are therefore not surprising. What can be done to improve the health of South Africans? Many and varied interventions are required, some at the population level, such as tobacco regulations, and others targeted at individuals, for example, adequate diagnosis and treatment of hypertension. This takes us to the policy report card. In the policy arena, the most successful interventions probably have been tobacco regulations, which have resulted in measurable declines in smoking rates, and food policies such as the tax on sugarsweetened beverages and micronutrient fortification of foods. Tobacco, food and alcohol regulation are promulgated at a national level and, given sufficient governmental will to overcome pushback from industry, implementation is relatively easy. The effectiveness of pushback from industry should, however, not be underestimated and is illustrated by the issue of alcohol. Many policy changes have been proposed, for example, increasing the age at which alcohol can be bought and reducing the legal driving limit to zero, but none of these policies have been implemented yet. Dealing with other lifestyle factors, such as lack of physical activity, is much more difficult because it not only requires providing a safe environment conducive to physical activity, but also requires motivating the individual. Similarly, physiological risk factors such as diabetes, hypertension and dyslipidaemia require significant improvements to our healthcare system. We need to have a healthcare system that effectively engages with the population in screening, correctly identifies risks, and provides the correct advice and treatment reliably and regularly without impacting on the ability of middle-aged adults to continue working due to day-long clinic visits. Here the task will not so much be policy formulation, although there are still some areas, such as diabetes management in which policies can be improved, but effective implementation of policies. This report card should serve as a wake-up call to all interested in the health of South Africans. As a nation we have done reasonably well in a few isolated areas, but we need to improve our overall performance considerably to maintain the health of the nation. References 1. Mayosi BM, Flisher AJ, Lalloo UG, Sitas F, Tollman SM, Bradshaw D. The burden of non-communicable diseases in South Africa. Lancet 2009; 374(9693): 934–947. 2. Gallo A, Charriere S, Vimont A, Chapman MJ, Angoulvant D, Boccara F, et al. SAFEHEART risk-equation and cholesterol-year-score are powerful predictors of cardiovascular events in French patients with familial hypercholesterolemia. Atherosclerosis 2020; 306: 41–49. 3. Stewart S, Carrington M, Pretorius S, Methusi P, Sliwa K. Standing at the crossroads between new and historically prevalent heart disease: effects of migration and socio-economic factors in the Heart of Soweto cohort study. Eur Heart J 2011; 32(4): 492–499. 4. Solanki G, Kelly G, Cornell J, Daviaud E, Geffen L. Population ageing in South Africa: trends, impact, and challenges for the health sector. S Afr Health Rev 2019; 2019(1): 175–182. 5. Restrepo C, Tracy RE. Variations in human aortic fatty streaks among geographic locations. Atherosclerosis 1975; 21(2): 179–193. 6. Lejarraga H. Perinatal origin of adult diseases. Arch Argent Pediatr 2019; 117(3): e232–e242. 7. Micklesfield LK, Kolkenbeck-Ruh A, Mukoma G, Prioreschi A, SaidMohamed R, Ware L, et al. The Healthy Aging Adult South Africa report card: a systematic review of the evidence between 2013 and 2020 for middle-aged South African men and women. S Afr J Cardiovasc Dis 2022; 33(4): 200–219.
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