Books: The Cholesterol Myth. The New Healthy Heart Programme

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The major risk factors for coronary artery disease in the Coloureds of the Cape Peninsula : The CRISIC Study

A cross-sectional study of risk factors for coronary heart disease (CHD) in a random sample of 976 coloured people revealed a population greatly at risk of CHD. The major reversible risk factors were very common: 57% of men and 41% of women smoked, 17,2% of men and 18,4% of women were hypertensive (>160/95 mm Hg or receiving medication), and 17,4% of men and 16,2% of women had a total serum cholesterol value above 6,5 mmol/litre. The high cut-off points used to identify the above prevalence rate do not reflect the total population at risk. At lower but real levels of risk 94,6% of men and 89,8% of women carried some degree of CHD risk factors was found

Where does the black population of South Africa stand on the nutrition transition?

OBJECTIVE: To review data on selected risk factors related to the emergence of noncommunicable diseases (NCDs) in the black population of South Africa. METHODS: Data from existing literature on South African blacks were reviewed with an emphasis placed on changes in diet and the emergence of obesity and related NCDs. DESIGN: Review and analysis of secondary data over time relating to diet, physical activity and obesity and relevant to nutrition-related NCDs. SETTINGS: Urban, peri-urban and rural areas of South Africa. National prevalence data are also included. SUBJECTS: Black adults over the age of 15 years were examined. RESULTS: Shifts in dietary intake, to a less prudent pattern, are occurring with apparent increasing momentum, particularly among blacks, who constitute three-quarters of the population. Data have shown that among urban blacks, fat intakes have increased from 16.4% to 26.2% of total energy (a relative increase of 59.7%), while carbohydrate intakes have decreased from 69.3% to 61.7% of total energy (a relative decrease of 10.9%) in the past 50 years. Shifts towards the Western diet are apparent among rural African dwellers as well. The South African Demographic and Health Survey conducted in 1998 revealed that 31.8% of African women (over the age of 15 years) were obese (body mass index (BMI) > or = 30kg m(-2)) and that a further 26.7% were overweight (BMI > or = 25 to <30 kg m(-2)). The obesity prevalence among men of the same age was 6.0%, with 19.4% being overweight. The national prevalence of hypertension in blacks was 24.4%, using the cut-off point of 140/90 mmHg. There are limited data on the population's physical activity patterns. However, the effects of the HIV/AIDS epidemic will become increasingly important. CONCLUSIONS: The increasing emergence of NCDs in black South Africans, compounded by the HIV/AIDS pandemic, presents a complex picture for health workers and policy makers. Increasing emphasis needs to be placed on healthy lifestyles

Determinants and treatment of hypertension in South Africans: the first demographic and health survey

Objectives: To identify the groups of patients with high prevalence and poor control of hypertension in South Africa. Methods: In the first national Demographic and Health Survey, 12 952 randomly selected South Africans, aged 15 years and older were surveyed. Trained interviewers completed questionnaires on socio-demographic characteristics, lifestyle and the management of hypertension. This cross-sectional survey also included blood pressure, height and weight measurements. Logistic regression analyses identified the determinants of hypertension and the treatment status in this dataset. Results: A high risk of hypertension was associated with less than tertiary education, older age groups, overweight and obese people, using alcohol in excess, and a family history of stroke and hypertension. Rural Africans had the lowest risk of hypertension, which was significantly higher in obese African women than in women with normal body mass index. Improved hypertension control was found in the wealthy, women, older persons, being Asian, and having medical insurance. Conclusions: Rural African people had lower hypertension prevalence rates than the other groups. The poorer, younger men, without health insurance had the worst level of hypertension control

Trends in adult tobacco use from two South African demographic and health surveys conducted in 1998 and 2003

Introduction: Since tobacco use peaked in the early 1990s in South Africa, it has declined significantly. This reduction has been attributed to the government’s comprehensive tobacco control policies that were introduced in the 1990s. Objective: To assess the pattern of tobacco use between the South African Demographic and Health Surveys in 1998 and 2003. Methods: Multi-stage sampling was used to select approximately 11 000 households in cross-sectional national surveys. Face-to-face interviews, conducted with 13 826 adults (41% men) aged ≥15 years in 1998 and 8 115 (42% men) in 2003, included questions on tobacco use according to the WHO STEP-wise surveillance programme. Logistic regression analysis was used to assess the independent effects of selected characteristics on smoking prevalence. Results: Daily or occasional smoking prevalence among women remained unchanged at 10-11%; among men it decreased from 42% (1998) to 35% (2003). The decline for men was significant among the poorest and those aged 25-44 years. Strong age patterns were observed, peaking at 35-44 years, which was reduced for men in 2003. Higher income and education were associated with low prevalence of smoking while living in urban areas was associated with higher rates. African men and women smoked significantly less than other population groups. Conclusion: Despite decreasing smoking rates in some subgroups, a gap exists in the efforts to reduce tobacco use as smoking rates have remained unchanged in women and young adults, aged 15-24 years

Estimating the burden of disease attributable to high cholesterol in South Africa in 2000

Objectives. To estimate the burden of disease attributable to high cholesterol in adults aged 30 years and older in South Africa in 2000.Design. World Health Organization comparative risk assessment (CRA) methodology was followed. Small community studies were used to derive the prevalence by population group. Population-attributable fractions were calculated and applied to revised burden of disease estimates for the relevant disease categories for each population group. The total attributable burden for South Africa in 2000 was obtained by adding the burden attributed to high cholesterol for the four population groups. Monte Carlo simulation-modelling techniques were used for uncertainty analysis.Setting. South Africa.Subjects. Black African, coloured, white and Indian adults aged 30 years and older.Outcome measures. Mortality and disability-adjusted life years (DALYs) from ischaemic heart disease (IHD) and ischaemic stroke.Results. Overall, about 59% of IHD and 29% of ischaemic stroke burden in adult males and females (30+ years) were attributable to high cholesterol ( ≥ 3.8 mmol/l), with marked variation by population group. High cholesterol was estimated to have caused 24 144 deaths (95% uncertainty interval 22 404 - 25 286) or 4.6% (95% uncertainty interval 4.3 - 4.9%) of all deaths in South Africa in 2000. Since most cholesterol-related cardiovascular disease events occurred in middle or old age, the loss of life years comprised a smaller proportion of the total: 222 923 DALYs (95% uncertainty interval 206 712 - 233 460) or 1.4% of all DALYs (95% uncertainty interval 1.3 - 1.4%) in South Africa in 2000.Conclusions. High cholesterol is an important cardiovascular risk factor in all population groups in South Africa

Estimating the burden of disease attributable to high blood pressure in South Africa in 2000

Objectives\ud \ud To estimate the burden of disease attributable to high blood pressure (BP) in adults aged 30 years and older in South Africa in 2000. \ud \ud Design\ud \ud World Health Organization comparative risk assessment (CRA) methodology was followed. Mean systolic BP (SBP) estimates by age and sex were obtained from the 1998 South African Demographic and Health Survey adult data. Population-attributable fractions were calculated and applied to revised burden of disease estimates for the relevant disease categories for South Africa in 2000. Monte Carlo simulation modelling techniques were used for uncertainty analysis. \ud \ud Setting\ud \ud South Africa\ud \ud Subjects\ud \ud Adults aged 30 years and older. \ud \ud Outcome measures\ud \ud Mortality and disability-adjusted life years (DALYs) from ischaemic heart disease (IHD), stroke, hypertensive disease and other cardiovascular disease (CVD). \ud \ud Results\ud \ud High BP was estimated to have caused 46 888 deaths (95% uncertainty interval 44 878 - 48 566) or 9% (95% uncertainty interval 8.6 - 9.3%) of all deaths in South Africa in 2000, and 390 860 DALYs (95% uncertainty interval 377 955 - 402 256) or 2.4% of all DALYs (95% uncertainty interval 2.3 - 2.5%) in South Africa in 2000. Overall, 50% of stroke, 42% of IHD, 72% of hypertensive disease and 22% of other CVD burden in adult males and females (30+ years) were attributable to high BP (systolic BP ≥ 115 mmHg). \ud \ud Conclusions\ud \ud High BP contributes to a considerable burden of CVD in South Africa and results indicate that there is considerable potential for health gain from implementing BP-lowering interventions that are known to be highly costeffective

A high burden of hypertension in the urban black population of Cape Town: the cardiovascular risk in Black South Africans (CRIBSA) study

Objective To determine the prevalence, associations and management of hypertension in the 25-74-year-old urban black population of Cape Town and examine the change between 1990 and 2008/09 in 25-64-year-olds. METHODS: In 2008/09, a representative cross-sectional sample, stratified for age and sex, was randomly selected from the same townships sampled in 1990. Cardiovascular disease risk factors were determined by administered questionnaires, clinical measurements and fasting biochemical analyses. Logistic regression models evaluated the associations with hypertension. RESULTS: There were 1099 participants, 392 men and 707 women (response rate 86%) in 2008/09. Age-standardised hypertension prevalence was 38.9% (95% confidence interval (CI): 35.6-42.3) with similar rates in men and women. Among 25-64-year-olds, hypertension prevalence was significantly higher in 2008/09 (35.6%, 95% CI: 32.3-39.0) than in 1990 (21.6%, 95% CI: 18.6-24.9). In 2008/09, hypertension odds increased with older age, family history of hypertension, higher body mass index, problematic alcohol intake, physical inactivity and urbanisation. Among hypertensive participants, significantly more women than men were detected (69.5% vs. 32.7%), treated (55.7% vs. 21.9%) and controlled (32.4% vs. 10.4%) in 2008/09. There were minimal changes from 1990 except for improved control in 25-64-year-old women (1990∶14.1% vs. 2008/09∶31.5%). CONCLUSIONS: The high and rising hypertension burden in this population, its association with modifiable risk factors and the sub-optimal care provided highlight the urgent need to prioritise hypertension management. Innovative solutions with efficient and cost-effective healthcare delivery as well as population-based strategies are required

Effectiveness of a group diabetes education programme in underserved communities in South Africa: pragmatic cluster randomized control trial

BACKGROUND: Diabetes is an important contributor to the burden of disease in South Africa and prevalence rates as high as 33% have been recorded in Cape Town. Previous studies show that quality of care and health outcomes are poor. The development of an effective education programme should impact on self-care, lifestyle change and adherence to medication; and lead to better control of diabetes, fewer complications and better quality of life. METHODS: Trial design: Pragmatic cluster randomized controlled trialParticipants: Type 2 diabetic patients attending 45 public sector community health centres in Cape TownInterventions: The intervention group will receive 4 sessions of group diabetes education delivered by a health promotion officer in a guiding style. The control group will receive usual care which consists of ad hoc advice during consultations and occasional educational talks in the waiting room.Objective: To evaluate the effectiveness of the group diabetes education programmeOutcomes: Primary outcomes: diabetes self-care activities, 5% weight loss, 1% reduction in HbA1c. Secondary outcomes: self-efficacy, locus of control, mean blood pressure, mean weight loss, mean waist circumference, mean HbA1c, mean total cholesterol, quality of lifeRandomisation: Computer generated random numbersBlinding: Patients, health promoters and research assistants could not be blinded to the health centre's allocationNumbers randomized: Seventeen health centres (34 in total) will be randomly assigned to either control or intervention groups. A sample size of 1360 patients in 34 clusters of 40 patients will give a power of 80% to detect the primary outcomes with 5% precision. Altogether 720 patients were recruited in the intervention arm and 850 in the control arm giving a total of 1570.DISCUSSION:The study will inform policy makers and managers of the district health system, particularly in low to middle income countries, if this programme can be implemented more widely.TRIAL REGISTER:Pan African Clinical Trial Registry PACTR20120500038038

The roles of community health workers in management of non-communicable diseases in an urban township

BACKGROUND: Community health workers (CHWs) are increasingly being recognised as a crucial part of the health workforce in South Africa and other parts of the world. CHWs have taken on a variety of roles, including community empowerment, provision of services and linking communities with health facilities. Their roles are better understood in the areas of maternal and child health and infectious diseases (HIV infection, malaria and tuberculosis). AIM: This study seeks to explore the current roles of CHWs working with non-communicable diseases (NCDs). Setting: The study was conducted in an urban township in Cape Town, South Africa. Method: A qualitative naturalistic research design utilising observations and in-depth interviews with CHWs and their supervisors working in Khayelitsha was used. Results: CHWs have multiple roles in the care of NCDs. They act as health educators, advisors, rehabilitation workers and support group facilitators. They further screen for complications of illness and assist community members to navigate the health system. These roles are shaped both by expectations of the health system and in response to community needs. CONCLUSION: This study indicates the complexities of the roles of CHWs working with NCDs. Understanding the actual roles of CHWs provides insights into not only the competencies required to enable them to fulfil their daily functions, but also the type of training required to fill the present gaps. Introduction Community health workers (CHWs) are increasingly being recognised as a crucial part of the health workforce.1 In South Africa and worldwide, CHWs have provided health care to communities for many decades and have assumed a variety of roles, including communityWeb of Scienc