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Objective: To assess the impact of a food-based intervention on blood pressure (BP) in free-living South African men and women aged 50-75 years, with drug-treated mild-to-moderate hypertension., Methods: A double-blind controlled trial was undertaken in eighty drug-treated mild-to-moderate hypertensive subjects randomised to an intervention (n 40) or control (n 40) arm. The intervention was 8-week provision of six food items with a modified cation content (salt replacement (SOLO ), bread, margarine, stock cubes, soup mix and a flavour enhancer) and 500 ml of maas (fermented milk)/d. The control diet provided the same quantities of the targeted foods but of standard commercial composition and 500 ml/d of artificially sweetened cooldrink., Findings: The intervention effect estimated as the contrast of the within-diet group changes in BP from baseline to post-intervention was a significant reduction of 6.2 mmHg (95 % CI 0.9, 11.4) for systolic BP. The largest intervention effect in 24 h BP was for wake systolic BP with a reduction of 5.1 mmHg (95 % CI 0.4, 9.9). For wake diastolic BP the reduction was 2.7 mmHg (95 % CI -0.2, 5.6)., Conclusions: Modification of the cation content of a limited number of commonly consumed foods lowers BP by a clinically significant magnitude in treated South African hypertensive patients of low socio-economic status. The magnitude of BP reduction provides motivation for a public health strategy that could be adopted through lobbying of the food industry by consumer and health agencies.

Background: In South Africa (SA) cardiovascular disease (CVD) is the second leading cause of death, with hypertension (HTN) being the predominant contributor to morbidity and mortality associated with this disease. We examined the prevalence and determinants of target organ damage (TOD) among urban black hypertensive South Africans attending primary health-care (PHC) services in Cape Town., Methods: Patients on HTN treatment, 35-65 years of age, participated in this cross-sectional study. Data relating to sociodemographic factors, medical history, lifestyle patterns, and HTN care regimens were obtained. Blood and urine samples were analyzed and electrocardiographs (ECGs) were recorded. Sokolow-Lyon and Minnesota Code (MC) criteria were used for identifying left ventricular hypertrophy (LVH). Reduced creatinine clearance (Cockroft-Gault), microalbuminuria, proteinuria, and elevated serum creatinine levels were used for identifying "renal impairment by any criteria" (RIC). Ischemic ECG patterns were classified in terms of MC criteria. Multivariate logistic regression analyses were carried out to identify variables independently associated with TOD., Results: The study sample comprised 403 participants. RIC was identified in 26%, LVH in 35%, and ischemic ECG patterns in 49% of the participants. Uncontrolled HTN and an absence of diabetes were associated with LVH as per Sokolow-Lyon criteria. Older age, the presence of diabetes, and the use of beta-blockers were associated with RIC. Ischemic ECG patterns were associated with uncontrolled HTN, older age, male gender, the consumption of less alcohol, and higher levels of low-density lipoprotein cholesterol (LDL-C)., Conclusions: TOD is common in this group of black hypertensive patients attending PHC sites. Uncontrolled HTN and older age were most often associated with TOD. Reducing the burden of TOD will require improving the quality of HTN care in PHC settings.

Objectives: To identify health care provider-related determinants of diabetes and hypertension management in patients attending public sector community health centres (CHCs)., Methods: A random sample of 18 CHCs in the Cape Peninsula providing hypertension and diabetes care was selected. Twenty-five patients with diabetes and 35 with hypertension per clinic were selected and interviewed by trained fieldworkers, and their medical records were audited. Regression analyses identified predictors of controlled hypertension (< 140/90 mmHg) and diabetes (HbA1c < 7%). In-depth interviews with nurses and doctors explored their experiences in working at the CHCs. Height, weight and blood pressure (BP) were measured for all patients and random blood samples collected for lipids, glucose, HbA1c and creatinine., Results: Of the participants 923 had hypertension and 455 diabetes (289 had both conditions). Of the hypertensive patients 33% had a BP < 140/90 mmHg, while 42% of the patients with diabetes had non-fasting glucose levels below 11.1 mmol/l. Patients' knowledge about their conditions was poor. Prescriptions for drugs were not recorded in medical records of 22.6% of the patients with diabetes and 11.4% of those with hypertension., Conclusions: Primary care for patients with hypertension and diabetes at public sector CHCs is suboptimal. This study highlights the urgent need to improve health care for patients with these conditions in public sector clinics in the Cape Peninsula.

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 included blood pressure, height and weight measurements. Logistic regression analyses identified the determinants of hypertension and the treatment status., Results: A high risk of hypertension was associated with less than tertiary education, older age groups, overweight and obese people, excess alcohol use, and a family history of stroke and hypertension. Hypertension risk was lowest in rural blacks and significantly higher in obese black women than in women with a normal body mass index. Improved hypertension control was found in the wealthy, women, older persons, Asians, and persons with medical insurance., Conclusions: Rural black people had lower hypertension prevalence rates than the other groups. Poorer, younger men without health insurance had the worst level of hypertension control.

Aims: Coronary heart disease (CHD) is a leading cause of death among men and women globally. Women develop CHD about 10 years later than men, yet the reasons for this are unclear. The purpose of this report is to determine if differences in risk factor distributions exist between women and men across various age categories to help explain why women develop acute MI later than men., Methods and Results: We used the INTERHEART global case-control study including 27 098 participants from 52 countries, 6787 of whom were women. The median age of first acute MI was higher in women than men (65 vs. 56 years; P < 0.0001). Nine modifiable risk factors were associated with MI in women and men. Hypertension [2.95(2.66 -3.28) vs. 2.32(2.16-2.48)], diabetes [4.26(3.68-4.94) vs. 2.67(2.43-2.94), physical activity [0.48(0.41-0.57) vs. 0.77(0.71-0.83)], and moderate alcohol use [0.41(0.34-0.50) vs. 0.88(0.82-0.94)] were more strongly associated with MI among women than men. The association of abnormal lipids, current smoking, abdominal obesity, high risk diet, and psychosocial stress factors with MI was similar in women and men. Risk factors associations were generally stronger among younger individuals compared to older women and men. The population attributable risk (PAR) of all nine risk factors exceeded 94%, and was similar among women and men (96 vs. 93%). Men were significantly more likely to suffer a MI prior to 60 years of age than were women, however, after adjusting for levels of risk factors, the sex difference in the probability of MI cases occurring before the age of 60 years was reduced by more than 80%., Conclusion: Women experience their first acute MI on average 9 years later than men. Nine modifiable risk factors are significantly associated with acute MI in both men and women and explain greater than 90% of the PAR. The difference in age of first MI is largely explained by the higher risk factor levels at younger ages in men compared to women.

Objective: To develop a reduced-sodium bread in which salt (NaCl) is partially replaced with potassium, magnesium and calcium salts., Methods: Experimental bread was compared against standard brown bread, after a drop test (to assess whether bread quality deteriorates with abuse) and after the usual baking practices for baking properties (volume, crust colour, crumb colour and cell structure), sensory properties and nutritional composition. Plant production feasibility was evaluated in an industrial plant. Breads produced there were subjected to sensory evaluation using triangulation tests in a panel of 122 consumers. Twenty-four samples of both standard and experimental bread were laboratory-analysed for sodium, potassium, magnesium and calcium content., Results and Conclusion: A 32.3% reduced-sodium brown bread was developed that was acceptable in terms of baking qualities, appearance, texture and taste. The potassium, magnesium and calcium contents of the bread were increased by 55.2%, 69.0%, and 34.8%, respectively.

Objective: To describe the HiHi Study and assess cardiovascular disease (CVD) risk profile and comorbid conditions of Black patients receiving hypertension (HTN) care., Design: Cross sectional, descriptive., Setting: Public and private primary care sites in three townships near Cape Town, South Africa., Participants: 403 hypertensive Black patients (183 men, 220 women), ages 35-65 years., Methods: Self-reported sociodemographic, lifestyle, and medical history factors were assessed. Height, weight, and blood pressure (BP) were measured and 12-lead electrocardiogram recorded. Blood and urine were collected to assess lipid profile, diabetes, and renal impairment. Type and number of medications were abstracted from medical records., Results: Antihypertensive medication was prescribed for all participants, with HTN controlled (BP<140/90 mm Hg) for 36% of public and 51% of private patients. Mean systolic and diastolic BP were higher in the public than private sector (148/90 +/- 28/13 and 138/ 86 +/- 21/13 mm Hg) as was LVH (37% and 30%) but diabetes (18% and 29%) and obesity (55% and 75%) were less common in the public sector. There were no significant differences between public and private settings in use of antihypertensive medications, total cholesterol > or =5 mmol/L, daily tobacco use, or total CVD risk. More men than women smoked tobacco daily (30% and 6%) and used alcohol excessively (53% and 15%)., Conclusions: Despite attending HTN primary care, CVD risk factors were addressed inadequately. Differences in risk factor prevalence and control were identified by healthcare sector and sex. A critical need exists to improve HTN care and CVD risk management programs for this high risk group.

Objective: To examine determinants of hypertension (HTN) care and control among peri-urban hypertensive Black South Africans., Design: Cross-sectional, descriptive., Setting: Public and private primary care sites in three townships near Cape Town, South Africa., Participants: 403 hypertensive Black patients (183 men, 220 women), ages 35-65 years., Methods: The Precede-Proceed Model guided the study. Self-report sociodemographics, medical history, health behaviors, health service utilization, quality of life, social support, and exposure to life threats and illness were assessed. Blood pressure (BP) was measured and height and weight recorded., Results: Mean BP (mm Hg) was 151/99 for men, 142/88 for women with BP controlled (<140/90 mm Hg) among 33% of men, 44% of women. Patient-related barriers to HTN care included limited HTN-related knowledge, poor quality of life and stressors such as family death. An unhealthy lifestyle involving smoking cigarettes, physical inactivity and using alcohol excessively was common. In regression models of select socioeconomic, lifestyle risk and HTN care variables, significant predictors of lower SBP and DBP or BP control included: fewer antihypertensive medications, better compliance to HTN recommendations, younger age, female, higher education level, not using alcohol excessively, and private sector healthcare., Conclusion: This study identified a high level of barriers to HTN control and the need for comprehensive multilevel interventions to improve HTN care and control in this high-risk population. Furthermore, the data illustrate that the Hill-Bone compliance scale can be a practical tool in primary healthcare settings to identify patient-related factors and guide counseling to improve adherence in HTN care.

Objectives: Hypertension is prevalent, under-diagnosed, and inadequately treated in Black South Africans. However, few studies have addressed barriers to hypertension care and control in this community. The aim of this study was to validate the Hill-Bone Compliance to High Blood Pressure Therapy Scale (HB Comp Scale) for use in a South African primary healthcare setting. This instrument consists of three subscales, medications-compliance, appointment making, and salt intake., Methods: A demographic questionnaire and the HB scale were translated into the first language of the subjects and then back-translated into English. Hypertensive patients (N=98) were recruited from primary healthcare clinics in Cape Town. Blood pressure was measured with an Omron electronic blood pressure manometer, after 5 min of seated rest. Item-analysis was conducted to determine internal consistency of the HB Comp Scale; Spearman rank order correlations were used to assess the relationship between compliance scores and blood pressure., Results: A modified scale consisting of only 10 items demonstrated reasonable internal consistency (item-total correlations all >.31, and a standardized Cronbach alpha of 0.79), with an average interitem correlation of .26. In addition, the modified scale had significant predictive validity in that noncompliance predicted higher diastolic blood pressures (p=.21, P<.05) and medication noncompliance tended to predict higher systolic blood pressures (p=.20, P<.06). Appointment-making and dietary salt-intake subscales were not internally consistent., Conclusions: We demonstrated criterion validity and internal consistency for a modified Hill-Bone Compliance Scale, in Black, urban, hypertensive, South African patients. Results compare favorably with those from an urban African-American setting (standardized Cronbach alpha was .74-.84).

Background: Coronary heart disease (CHD) was uncommon in Black people living in Africa before 1970. Since then CHD risk factor levels have increased, while CHD rates have remained low., Objective: This case-control study aims to assess the relationship between CHD and known risk factors in urban Black South Africans., Methods: Eighty-nine cases with CHD and 356 controls attending the Kalafong hospital were recruited between 1982 and 1986 and followed up until 1994. Family and personal medical histories were recorded, along with a clinical examination and special investigations to assess risk factor profiles, clinical presentation and target organ damage. The relationship of the risk factors, target organ damage, and the development of CHD was assessed by using a stepwise multiple logistic regression procedure., Results: Far more cases than controls had a family and personal medical history and risk factors related to CHD. Those relating to the development of CHD were family history of myocardial infarction (odds ratio [OR] 17.29; 95% confidence interval [CI] 5.48-54.51), hypertension (OR 8.38, 95% CI 3.66-19.17), family history of hypertension (OR 4.33, 95% CI 2.21-8.52), low high-density lipoprotein cholesterol/low-density lipoprotein cholesterol ratio (OR 2.82, 95% CI 1.24-7.22), and type 2 diabetes (OR 2.99, 95% CI 1.19-6.68). Hypercholesterolemia was marginally associated (OR 2.53, 95% CI .92-6.89)., Conclusions: Evidence is provided that an association exists between CHD and the major risk factors for cardiovascular diseases in urban Black South Africans. A relationship between genetic factors and the development of CHD was also identified in this population group.

This article describes the patterns and effects of maternal snuff use, cigarette smoking and exposure to environmental tobacco smoke during pregnancy on birthweight and gestational age, in women living in Johannesburg and Soweto in 1990. A cohort of 1593 women with singleton live births provided information about their own and household members' usage of tobacco products during pregnancy. The women completed a questionnaire while attending antenatal services. Data on gestational age and birthweight were obtained from birth records. Women who smoked cigarettes or used snuff during pregnancy accounted for 6.1% and 7.5% of the study population respectively. The mean birthweight of non-tobacco users was 3148 g [95% CI 3123, 3173] and that of the smokers 2982 g [95% CI 2875, 3090], resulting in a significantly lower mean birthweight of 165 g for babies of smoking mothers (P = 0.005). In contrast, women using snuff gave birth to infants with a mean birthweight of 3118 g [95% CI 3043, 3192], which is a non-significant (P = 0.52) decrease (29.4 g) in their infants' birthweights compared with those not using tobacco. A linear regression analysis identified short gestational age, female infant, a mother without hypertension during pregnancy, coloured (mixed racial ancestry), and Asian infants compared with black infants, lower parity, less than 12 years of education and smoking cigarettes as significant predictors of low birthweight, while the use of snuff during pregnancy was not associated with low birthweight. The snuff users, however, had a significant shorter gestational age than the other two groups of women. The birthweight reduction adjusted for possible confounders was 137 g [95% CI 26.6, 247.3 (P = 0.015)] for cigarette smokers and 17.1 g [95% CI -69.5, -102.7, P = 0.69] for snuff users respectively, compared with the birthweight of non-tobacco users. Among women who did not smoke cigarettes or use snuff, exposure to environmental tobacco smoke did not result in significant effects on the birthweight of their infants. In conclusion, infants of cigarette smokers had significantly lower birthweights than those of non-tobacco users or snuff users who are exposed to nicotine during pregnancy. Passive smoking did not affect birthweight significantly in this population.

Objectives: To determine any differences in the urinary excretion and dietary intake of sodium, potassium, magnesium and calcium intake in three South African ethnic groups, and to assess whether the blood pressure-cation association varies according to ethnic status., Design: A cross-sectional study of 325 black, white and mixed-ancestry men and women, conveniently sampled in Cape Town. Twenty-four-hour urine samples were collected on three separate occasions for assessment of urinary electrolytes, and three 24-h dietary recalls for the corresponding urine collection times were administered by two trained fieldworkers. Para-amino benzoic acid was used as a marker of the completeness of urine collection., Results: Mean urinary sodium values equate to a daily salt (sodium chloride) intake of 7.8, 8.5 and 9.5 g in black, mixed-ancestry and white individuals, respectively. In normotensive individuals, black and mixed-ancestry subjects had significantly lower median urinary sodium concentrations than white subjects, but these differences were not evident between black and white hypertensive subjects. No ethnic differences were found for urinary potassium, except for mixed-ancestry normotensive individuals having a lower excretion than white normotensive individuals. Urinary magnesium excretion did not differ across ethnic groups. In both normotensive and hypertensive individuals, urinary calcium concentrations differed between all three groups, with black subjects having the lowest values, approximately less than half those of white subjects., Conclusion: White normotensive subjects in Cape Town have higher habitual intakes of sodium, but also higher calcium intakes than their black and mixed-ancestry counterparts. Dietary differences may contribute to ethnic-related differences in blood pressure.

Background: To determine the prevalence and associated risk factors of cardiovascular diseases in a rural adult black population from Limpopo Province in South Africa., Design: A cross-sectional study., Methods: A sample of 1608 women and 498 men aged 30 years and above participated in the study. Sociodemographic data, anthropometric measures (body mass index, waist/hip ratio), blood pressure and biochemical risk factors were measured. A global cardiovascular disease (CVD) risk profile was developed., Results: There was a high prevalence of tobacco use for men (57%) and women (35.4%), with women (28.1%) predominantly using smokeless tobacco. Alcohol use was very common in men (57.2%). Women weighed a great deal more than men, and 51.7% were either overweight or obese. Diabetes was diagnosed in 8.8 and 8.5% of women and men, respectively. High-density lipoprotein-cholesterol was relatively high, whereas 42.3% of women and 28.5% of men had low-density lipoprotein-cholesterol levels of 3 mmol/l or more. Hypertension (blood pressure > or =140/90 mmHg) was found in 25.5% of women and 21.6% of men. According to the Framingham formulae, 18.9% of women and 32.1% of men had a 20% or higher chance of having a CVD event in the next 10 years., Conclusions: There was a high prevalence of chronic disease risk factors in the rural, poor black community in Limpopo, South Africa. Consequently, the population had a higher than expected risk of developing a CVD event in the following 10 years when compared with similar studies in black Africans.

Objective: To investigate the current smoking cessation practices and attitudes of doctors working in the public antenatal services, as well as their perceived barriers to addressing the issue in the context of routine care., Study Design: The study was qualitative, consisting of 14 semistructured, one-to-one interviews with doctors purposefully sampled from 5 public sector hospitals in Cape Town, South Africa., Results: The doctors in this study regarded HIV, poor nutrition, alcohol abuse and psychosocial stress as equal or higher risks to pregnant women than smoking. They tended to underestimate the magnitude of the risk of smoking during pregnancy. Doctors were unaware of the guidelines offering clinicians brief, structured approaches to smoking cessation counselling and were generally pessimistic that they could influence the smoking behaviour of pregnant women, especially poor, disadvantaged women who face multiple barriers to achieving health-enhancing behaviour. However, most doctors were concerned about improving their communication with pregnant women about smoking and open to adopting new approaches or tools that could assist them. Perceived barriers to providing smoking cessation interventions included a lack of counselling skills and educational resources, other pressing priorities, too little time, and the levels of stress currently experienced by doctors and midwives working in public sector hospitals as a result of dramatic staff and budget cuts., Conclusion: The study suggests that doctors working in the public sector antenatal services are not routinely addressing the issue of smoking during pregnancy or using effective methods to assist women to give up smoking. Doctors need convincing that smoking cessation interventions can be effective. The promotion and provision of evidence-based guidelines such as the Clinical Practice Guideline for Treating Tobacco Use and Dependence (Fiore, 2000), with minimal training, is a possible strategy for integrating smoking cessation interventions into routine antenatal care in South Africa.

Purpose: To determine the prescribed drug-utilisation pattern for six common chronic conditions in adult South Africans in a cross-sectional survey., Methods: 13,826 randomly selected participants, 15 years and older, were surveyed by trained fieldworkers at their homes in 1998. Questionnaires included socio-demographic, chronic-disease and drug-use data. The prescribed drugs were recorded from participants' medication containers. The Anatomical Therapeutic Classification (ATC) code of the drugs for tuberculosis (TB), diabetes, hypertension, hyperlipidaemia, other atherosclerosis-related conditions, such as heart conditions or cerebrovascular accidents (CVA), and asthma or chronic obstructive pulmonary disease (COPD), was recorded. The use of logistic regression analyses identified the determinants of those patients who used prescription medication for these six conditions., Results: 18.4% of the women and 12.5% of the men used drugs for the six chronic conditions. Men used drugs most frequently for hypertension (50.9%) and asthma or chronic bronchitis (24.3%), while in women it was for hypertension (59.9%) and diabetes (17.5%). The logistic regression analyses showed that women, wealthier and older people, and those with medical insurance used these chronic-disease drugs more frequently compared to men, younger or poor people, or those without medical insurance. The African population group used these drugs less frequently than any other ethnic group. The inappropriate use of methyldopa was found for 14.8% of all antihypertensive drugs, while very few people used aspirin., Conclusions: The methodology of this study provides a means of ascertaining the chronic-disease drug-utilisation pattern in national health surveys. The pattern described, suggests an inequitable use of chronic-disease drugs and inadequate use of some effective drugs to control the burden of chronic diseases in South Africa.

This study investigated the use of the dichotic multiple frequency ASSR technique for characterising normal hearing in a group of infants. A descriptive research design was implemented to describe ASSR thresholds obtained in 10 normal hearing infant ears (3 male, 2 female participants) between the age of 3 and 8 weeks. Normal hearing was controlled for by conducting a DPOAE screening test on all ears and ensuring no risk factors for hearing loss were present. Results indicated mean ASSR thresholds at 0.5, 1, 2, and 4 kHz to vary between 30 and 37 dB, +/- 8 - 11 dB within a range of 20 - 50 dB HL. Eighteen percent of ASSR thresholds were obtained at 20 dB, 45% were obtained at 30 dB, and 38% were obtained at elevated levels of 40 and 50 dB. The recorded dichotic multiple frequency ASSR thresholds for infants with normal hearing were within the mild to moderate hearing loss range which makes differentiating between less severe degrees of hearing loss and normal hearing difficult. Until future research has been conducted, caution must be practiced when interpreting ASSR thresholds below 60 dB in young infants and additional techniques such as the ABR must be used to cross-check results.

Objectives: We investigated whether habitual intakes of sodium (Na), potassium, magnesium, and calcium differ across South African ethnic groups, assessed the proportion of Na intake, which is discretionary, and identified which food sources were the major contributors to Na intake., Methods: This was a cross-sectional study of 325 black, white, and mixed ancestry hypertensive and normotensive subjects. Three repeated 24-h urine samples were collected for assessment of urinary Na, and three corresponding 24-h dietary recalls were administered by trained fieldworkers. Blood pressure and weight were measured at each visit. Secondary analyses were performed on existing dietary databases obtained from four regional surveys undertaken in South African adults., Results: Mean urinary Na excretion values equated to daily salt (NaCl) intakes of 7.8, 8.5, and 9.5 g in black, mixed ancestry, and white subjects, respectively (P < 0.05). Between 33% and 46% of total Na intake was discretionary, and, of the non-discretionary sources, bread was the single greatest contributor to Na intake in all groups. Ethnic differences in calcium intake were evident, with black subjects having particularly low intakes. Urban versus rural differences existed with respect to sources of dietary Na, with greater than 70% of total non-discretionary Na being provided by bread and cereals in rural black South Africans compared with 49% to 54% in urban dwellers., Conclusion: White South Africans have higher habitual intakes of Na, but also higher calcium intakes, than their black and mixed ancestry counterparts. All ethnic groups had Na intakes in excess of 6 g/d of salt, whereas potassium intakes in all groups were below the recommended level of 90 mM/d. Dietary differences may contribute to ethnically related differences in blood pressure.

Objective: This study formed part of the 1998 South African Demographic and Health Survey, which included questions assessing the extent of alcohol use, risky drinking and alcohol problems among South Africans to obtain up-to-date baseline estimates of consumption and risky drinking and to inform intervention efforts., Method: A two-stage random sample of 13,826 persons ages 15 or older (59% women) was included in the survey. Alcohol use was assessed through eight questions, including the CAGE questionnaire. Frequency analyses for different age groups, geographic setting, education level, population group and gender were calculated, as were odds ratios for these variables in relation to symptoms of alcohol problems., Results: Current alcohol consumption was reported by 45% of the men and 17% of the women. White men (71%) were most likely and Asian women (9%) least likely to be current drinkers. Urban residents were more likely than nonurban dwellers to report current drinking. One third of the current drinkers reported risky drinking over weekends, and 28% of the men and 10% of the women scored above the cutoff level on the CAGE questionnaire. Symptoms of alcohol problems were significantly associated with lower socioeconomic status, no school education in women and being older than 25 years of age., Conclusions: A comprehensive strategy is required to address the high levels of risky drinking and reported symptoms of alcohol problems.

Setting: National household survey of adults in South Africa, a middle income country., Objective: To determine the prevalence and predictors of chronic bronchitis., Design: A stratified national probability sample of households was selected. All adults in the selected households were interviewed. Chronic bronchitis was defined as chronic productive cough. Socio-demographic predictors were wealth, education, race, age and urban residence. Personal and exposure variables included history of tuberculosis, domestic exposure to smoky fuels, occupational exposures, smoking and body mass index., Results: The overall prevalence of chronic bronchitis was 2.3% in men and 2.8% in women. The strongest predictor of chronic bronchitis was a history of tuberculosis (men, odds ratio [OR] 4.9; 95% confidence interval [CI] 2.6-9.2; women, OR 6.6; 95%CI 3.7-11.9). Other risk factors were smoking, occupational exposure (in men), domestic exposure to smoky fuel (in women) and (in univariate analysis only) being underweight. Wealth and particularly education were protective., Conclusion: The pattern of chronic bronchitis in South Africa suggests a combination of risk factors that includes not only smoking but also tuberculosis, occupational exposures in men and domestic fuel exposure in women. Control of these risk factors requires public health action across a broad front. The protective role of education requires elucidation.

Objectives: To describe the cardiovascular disease (CVD) risk factors and the global burden of CVD risk in a peri-urban, working-class community of Mamre near Cape Town. To identify additional variables in the data set associated with the global CVD risk factor score. The latter was calculated using the major CVD risk factors in formulas derived from the Framingham global CVD risk calculations. Such variables could possibly be used for global CVD risk calculations, instead of depending on biochemical estimates for these calculations., Methods: In a random population-based sample of 976 people aged 15 years and older, data on demography, smoking, physical activity, and alcohol use were collected. Blood pressure (BP), anthropometry, levels of serum glucose and lipids, and low-density lipoprotein cholesterol (LDL) particle sizes were also determined. These data allowed calculation of the global CVD risk profile with the Framingham study's formula. The data are age-standardized to the colored (mixed ancestry) population according to the 1996 South African census., Results: The global CVD risk score suggested that men and women had a 5.2% and 4.2% probability, respectively, of having a CVD event in the next 10 years, while for those 55 years of age and older, the probability increased to more than 30% and 25%, respectively. Hypertension was found in 22% of men and 16% of women. Sixty-two percent of the men and 44% of the women smoked cigarettes, while 6% and 5% had diabetes, respectively. Hypercholesterolemia was present in 47% of men, and 46% of women. Small-dense LDL particles were present in 26% of men and 14% of women. A number of easily measured CVD risk factors could explain 40.3% of the variation of the global CVD risk score. These include aspects of the medical history provided by the patient, the inverse of the amount of physical activity and weight measurements, as well as height, and waist circumference., Conclusions: The people in Mamre have a high probability of suffering a CVD event in the next 10 years. Age and gender are the primary contributors to the global CVD risk score. The findings suggest the possibility of developing a global CVD risk score based on easily measured CVD risk factors for use in developing countries with limited resources.

Objectives: To ascertain the anthropometric profile and determinants of obesity in South Africans who participated in the Demographic and Health Survey in 1998., Research Methods and Procedures: A sample of 13,089 men and women (age, > or =15 years) were randomly selected and then stratified by province and urban and nonurban areas. Height, weight, mid-upper arm circumference, and waist and hip circumference were measured. Body mass index (BMI) was used as an indicator of obesity, and the waist/hip ratio (WHR) was used as an indicator of abdominal obesity. Multivariate regression identified sociodemographic predictors of BMI and waist circumference in the data., Results: Mean BMI values for men and women were 22.9 kg/m(2) and 27.1 kg/m(2), respectively. For men, 29.2% were overweight or obese (> or =25 kg/m(2)) and 9.2% had abdominal obesity (WHR > or =1.0), whereas 56.6% of women were overweight or obese and 42% had abdominal obesity (WHR >0.85). Underweight (BMI <18.5 kg/m(2)) was found in 12.2% of men and 5.6% of women. For men, 19% of the variation of BMI and 34% of the variation in waist circumference could be explained by age, level of education, population group, and area of residence. For women, these variables explained 16% of the variation of BMI and 24% of the variation in waist circumference. Obesity increased with age, and higher levels of obesity were found in urban African women., Discussion: Overnutrition is prevalent among adult South Africans, particularly women. Determinants of overnutrition include age, level of education, ethnicity, and area of residence.

Objective: To determine smoking patterns in South Africa, and to identify groups requiring culturally appropriate smoking cessation programmes., Methods: A random sample of 13,826 people (> 15 years), was interviewed to identify tobacco use patterns and respiratory symptoms. Peak expiratory flow rates were measured. Multinomial regression analyses identified sociodemographic factors related to tobacco use, and the latter's association with respiratory conditions., Results: In 1998, 24.6% adults (44.2% of males and 11.0% of females) smoked regularly. Coloured women had a higher rate (39%) than African women (5.4%). About 24% of the regular smokers had attempted to quit, with only 9.9% succeeding. African women (13.2%) used smokeless tobacco more frequently than others. Of the nonsmokers 28% and 19% were exposed to environmental tobacco smoke in their homes and workplaces, respectively. The regression analysis showed that the demographic characteristics of light smokers (1-14 tobacco equivalents per day) and heavy smokers (> or = 15 tobacco equivalents per day) differed. Light smoking occurred significantly more frequently in the poorest, least educated and urban people. The relative risk for light smoking was 18 in Coloured women compared with African women. Heavy smoking occurred most frequently in the highest educated group. A dose-response was observed between the amount smoked and the presence of respiratory diseases., Conclusions: Smoking in South Africa is decreasing and should continue with the recently passed tobacco control legislation. Culturally appropriate tobacco cessation programmes for the identified target groups need to be developed.

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.

Oral diseases are widespread in South Africa and affect large numbers of people in terms of pain, tooth loss, disfigurement, loss of function and even death. The majority of South Africans have no access to private services and are dependent on the government for oral health care services, but less than 10% of the population utilises public oral health services. This underutilisation is due to limited resources and inaccessibility. This article reports on the data collected on adults, 15 years and older, from the South African Demographic and Health Survey carried out in 1998, relating to perceptions of oral health. The questions dealt with oral health problems, utilisation of oral health services, loss of natural teeth, oral health practices and knowledge of water fluoridation. The results are discussed in terms of age, gender, education, place of residence, province and classification according to the previous population registration act. A high proportion (36%) of people had experienced oral health problems. Teeth problems were most commonly reported in the higher age groups, non-urban areas, Eastern Cape, Northern Cape and Free State, people with little education and those classified as non-urban Africans. Significant differences were found in regard to periodontal disease, tooth loss, knowledge of fluoride between groups according to age, geographic location, race and level of education. 62% of the respondents reported that they had lost some of their natural teeth and in some communities almost a third of the respondents were edentulous. In comparing the goals of the current draft national oral health policy with the findings of this survey the following implications for policy development should be noted: A higher priority needs to be given to oral health issues; Improve access by increasing primary health care facilities through the delivery of oral health care services; The high prevalence of hepatitis and HIV/AIDS infection poses a higher risk to oral health personnel and the public and The successful implementation of water fluoridation depends upon public knowledge, understanding and support.

Objective: The objective of this study was: 1) to determine the anthropometric profile of adults in Mamre, a small town in South Africa, which has a population of mixed ancestry ("colored" people of Afro-Euro-Malay-Khoisan ancestry); and 2) to determine the change in this profile between 1989 and 1996., Design: Cross-sectional surveys conducted in random samples of adults in 1989 and 1996., Participants: The subjects were 684 women and 529 men in 1989, and 546 women and 430 men in 1996, aged 15 and older., Main Outcome Measures: The following measurements were recorded: height, weight, and circumference of waist, hips, and mid-upper arm., Results: Based on data from the 1996 survey, 32% of women are obese (body mass index [BMI] > or = 30) at ages 25-44 years, rising to 49% at ages 45-64 years. A much lower prevalence of obesity is seen in men: 14% at ages 35-64 years. Obesity levels significantly increased in women between the two surveys (P=.015): up from 44% in 1989 to 49% in 1996 at ages 45-64 years. There was an increase in the prevalence of overweight (BMI 25-29.9) in men, though not in obesity. Mean BMI increased by about 3% in women and 2% in men between 1989 and 1996., Conclusions: This study conducted among people of mixed ancestry living in a disadvantaged community in South Africa shows that half of middle-aged women are obese. A rising trend in BMI was seen in adults of both sexes between 1989 and 1996. This trend may be explained by factors associated with rural-urban transition, including electrification, reduced physical activity, and increasing availability of energy-dense food.

Objectives: To assess the feasibility of a 5-year community-based tobacco control program in the community of Mamre in South Africa, while measuring the smoking and quitting rates at the beginning and end of this demonstration project., Methods: A tobacco intervention program was developed at low cost in collaboration with the community, and involved a wide range of activities targeting people of all ages, especially those at risk for cardiovascular disease. Community members were trained to deliver smoking cessation programs and specific advice to smokers. Cross-sectional surveys were conducted in 1989 in a random sample of 1238 people, aged 15 years and older, prior to the 5-year demonstration project, and again in 1996 among 974 people at the end of the project. Demographic data and smoking and quitting patterns were collected by interviewer-administered questionnaires. Trained field workers used standardized procedures for recording blood pressure, height, and weight., Results: The community participated with enthusiasm in the activities surrounding smoking cessation and the annual World No Smoking Day. The smoking rate decreased significantly between the two surveys (OR 1996/1989 = 0.82; 95% CI of 0.69-0.99), and the quitting rate increased significantly during the 5-year intervention period compared to the 5 years prior to the baseline survey (OR 1996/1989 = 0.74; 95% CI of 0.57-0.98). Men who participated in the program but continued to use tobacco in 1996 smoked more cigarettes than those who smoked in 1989. People who quit during the intervention period tended to be older, hypertensive, and obese; they consumed no alcohol, and noticed the health warnings posted in the community if they were older and had 10 or more years of education., Conclusions: A low-cost community-based tobacco control program was successfully implemented in the Mamre community. The program was received enthusiastically, built tobacco cessation skills, and significantly reduced the community's smoking rate compared to that before the demonstration project.

Background: Consensus-derived guidelines for hypertension and diabetes management were introduced by the National Department of Health to improve quality of care. However, the incorporation of guidelines into clinical practice is largely dependent on the attitudes of health professionals., Objective: To audit the responses and examine the attitudes of health professionals in primary care towards the diabetes and hypertension care guidelines., Design: Qualitative focus group, in-depth discussions and clinic observations., Setting: Four community health centres (CHCs) in the Western Cape., Subjects: Fifteen doctors and 10 professional nurses., Methods: The responses of health professionals to the guidelines were audited. Their attitudes were evaluated at a single pilot CHC using focus group discussions and in-depth interviews. Semi-structured interviews based on these themes were conducted at 3 other CHCs. Clinic consultations were observed to validate the responses., Results: The guidelines were not systematically implemented at local CHCs and individual doctors consulted the guidelines infrequently. Several themes were identified as barriers to the application of the guidelines, including the consultation process by which the guidelines were developed, time constraints, scepticism about durability of the guidelines, conflict with local practices, health system problems, and patient beliefs., Conclusion: The usefulness of passive dissemination of guidelines to health professionals in primary care should be reviewed as several attitudinal barriers to implementation may exist. Guidelines may be adopted more readily if these barriers are addressed.

Background: A birth cohort study, the Birth to Ten (BTT) study, commenced in the greater Johannesburg/Soweto metropole in South Africa in 1990. The overall BTT project collected antenatal, birth and early development information on these children as well as information that could help identify factors related to the emergence of risk of cardiovascular diseases (CVDs) in children., Objective: To determine CVD risk profiles and their determinants in 5-year-old children living in an urban environment in South Africa., Methods: Demographic and birth characteristics were collected on a sample of 964 5-year-olds whose parents agreed for blood samples to be taken from their children. The children's height and weight were measured using standardised procedures; blood pressure (BP) was measured with a Dinamap Vital Signs Monitor, and a non-fasting blood sample was drawn for lipid determinations. Information on exposure to tobacco smoke and additional health-related data were obtained by interview., Results: No differences were found between the birth weight and gestational age of the 5-year-old CVD participants and the remainder of the children studied at birth. The systolic BP was significantly different between ethnic groups, with the BP of the black children significantly higher than that of the Indian and white children, while the diastolic BP of black children was also the highest. White children had the highest mean total cholesterol (TC) and low-density lipoprotein cholesterol (LDLC) levels, significantly higher than those in the black community. The coloured children's TC level was also significantly lower than that of the whites, while the LDLC level of the Indian children was significantly higher than that of the blacks. Overall, 64% of the children were exposed to environmental tobacco smoke (ETS), with the white group having the lowest rate (45% exposed to ETS). The coloured children were most frequently exposed to ETS, with 40.6% having primary caregivers who smoked; of these children 42% lived in homes with two or more smokers., Conclusions: Tobacco control legislation will protect South Africans against tobacco sales promotions. This will be the first step towards increasing the priority of chronic disease prevention, health promotion and appropriate care for chronic diseases and their risk factors on the South African health policy agenda. The groups of children that were studied carried differing but significant levels of CVD risk. This suggests that the promotion of a healthy lifestyle should start in childhood, and should target the risk factors found in each group.

Background: Guidelines to improve standards of care for hypertension and diabetes were disseminated by the National Department of Health in 1996 but have generally not been implemented by health professional in local primary care. A strategy for the adoption and implementation of the Guidelines was developed in collaboration with health professionals in primary care., Objectives: The development of a structured record, with prompts for the management of diabetes and hypertension according to the Guidelines., Setting: Three community health centres (CHCs) in the Western Cape., Participants: Doctors and nurses managing patients with diabetes and hypertension., Methods: A draft of the structured record was developed at a single-pilot CHC in the Western Cape. Focus group discussions established the core requirements for a structured record. Process, result and structural indicators in line with the national Guidelines were considered for inclusion in the draft record. This draft record was then piloted at two other CHCs. Comments from semi-structured interviews and pre- and post-test evaluation questionnaires were used to compile the final instrument., Results: Eleven doctors and 8 nurses participated in the development of the final instrument. Important considerations in the design were a single-page, user-friendly format, tick-boxes to reduce writing, prompts, provision for sequential recording, target setting, and compatibility with the Guidelines. The final instrument was piloted and elicited a favourable overall response., Conclusion: The structured record simplifies the application of the Guidelines and the systematic recording of processes of care. The effectiveness of the Guidelines will be evaluated further in a randomised control trial using the structured record.

Design: Case-control study among incident African patients with cancer. Questionnaire assessment of exposure to tobacco, occupation, and place of birth., Setting: Northern Province, South Africa., Subjects: Between 1993 and 1995, 288 men and 60 women with lung cancer and 183 male and 197 female controls (consisting of patients newly diagnosed with cancers other than those known to be associated with smoking) were interviewed. Unmatched, unconditional logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (95% CIs) of developing lung cancer in relation to a number of variables., Main Outcome Measure: Risk of developing lung cancer related to exposure to tobacco, indoor pollution, dusty work environment, and residential exposure to asbestos., Results: There was a significant increase in the risk of developing lung cancer through smoking. In men, the ORs were 2.2 (95% CI = 1.0 to 4. 6) in ex-smokers, 9.8 (95% CI = 5.9 to 16.4) in light smokers (0-14 g/day), and 12.0 (95% CI = 6.5 to 22.3) in heavy smokers. In women, the ORs were 5.8 (95% CI = 1.3 to 25.8) in ex-smokers and 5.5 (95% CI = 2.6 to 11.3) in current smokers. Work in a dusty industry showed an elevated risk (OR = 3.2, 95% CI = 1.8 to 5.8) for lung cancer only in men. Male residents of areas where asbestos was shipped for distribution (termed moderately polluted asbestos areas) had a 2.5-fold increase (95% CI = 1.0 to 4.4) in the risk (OR) of developing lung cancer, and residents of areas where asbestos was mined (termed heavily polluted asbestos areas) had a 2.8-fold increase in risk (95% CI = 0.7 to 10.4). Female residents of heavily polluted asbestos areas showed elevated risks of 5.4 (95% CI = 1.3 to 22.5) of developing lung cancer., Conclusion: The data suggest that tobacco smoking is the most important risk factor for the development of lung cancer in this setting. Risks for lung cancer are reminiscent of those observed in Western countries in the 1960s and 1970s. However, environmental exposure to asbestos, a dusty occupation (in men), and perhaps indoor air pollution may also contribute to the development of lung cancer in this province.

Aims: To investigate the prevalence of Type 2 diabetes mellitus (DM) and its risk factors in a working class peri-urban community in South Africa., Methods: A cross-sectional descriptive study was conducted in 1996, where all persons aged 15 years and older, who were resident in randomly selected houses in Mamre, 55 km from the centre of Cape Town, were sampled. Subjects underwent a 75-g oral glucose tolerance test. Socio-demographic and anthropometric data were obtained and physical activity was assessed using a 7-day activity recall questionnaire. The 1985 WHO criteria were used to define diabetes., Results: The response rate was 64.5% (n = 974). The participants comprised 56% women, 44% men, mean age 37.6 (range 15-86) years. The crude prevalence of Type 2 DM was 7.1% and impaired glucose tolerance (IGT) 8.0%. The age-adjusted prevalence of Type 2 DM was 10.8% (95% confidence interval (CI) 8.2-13.5%) and IGT 10.2% (95% CI 7.7-12.8%). Regression analysis indicated that age (risk ratio (RR) 7.40, 95% CI 3.45-15.86), waist circumference (RR 4.53, 95% CI 2.04-10.05), low total energy expenditure (RR 1.75, 95% CI 1.07-2.56) and family history of diabetes (RR 2.31, 95% CI 1.42-3.77) were independent risk factors for Type 2 DM, while sex, obesity and regular alcohol consumption were not., Conclusions: This previously unstudied community has an intermediate prevalence on the international scale of Type 2 DM, which is linked to potentially modifiable risk factors.

Objective: Social support, by moderating cardiovascular reactivity, has been demonstrated to attenuate the effects of stress on blood pressure in American communities. This is the first report to examine the relationship between social support and blood pressure in a South African context, during a period of infrastructure modernisation and political change., Methods: A total of 1240 residents (542 men, 698 women) of mixed ethnic origin, older than 14 years and stratified by age and sex, participated in a survey to determine risk factors for hypertension and cardiovascular diseases. Social support was assessed by a questionnaire developed in consultation with the community. It was defined by interactions that may threaten family harmony (score 1) and by networking between relatives, friends, colleagues and neighbours (score 2)., Results: Mean blood pressure of the sample was 130/79 mm Hg (s.d. 25/14 mm Hg). Hypertension prevalence was 26.9%. Only 36% of women compared to 57.3% of men (P < 0.0001) were employed. More women (29%) than men (22%) reported threats to family harmony, but social support networks were similarly perceived by both sexes. Systolic and diastolic blood pressure correlated weakly with score 1 (r = 0.096, P < 0.0007) but no association was observed with score 2. Score 1 was not associated with blood pressure by multiple regression analysis, that included confounding by age, sex, BMI, alcohol consumption and smoking status., Conclusions: Neither threats to family harmony nor networking between relatives, friends or neighbours, significantly influences blood pressure in this community. Measures of social support thought to moderate blood pressure may have limited cross-cultural application. Attitudinal changes during socio-political transition may impact on the generalisability of instruments for measurement.

Objective: This study was undertaken at a community health center (CHC) in the Cape Peninsula in order to assess the treatment status, knowledge and experiences of hypertensive patients. In addition, a health indicator sheet for hypertension was evaluated and an attempt was made to identify predictors of blood pressure (BP) control at this clinic., Methods: Two hundred two hypertensive patients were selected by interviewing the first available hypertensive patients. The patients' BP was measured electronically and by sphygmomanometer, and was compared to that recorded by the clinician on their clinic folders; heights and weights were also determined., Results: Of the hypertensives, 41.6% had a BP above 160/95 mm Hg and only 42.1% had a BP below 140/90 mm Hg. Patients had little knowledge of either the consequences of hypertension or the actions needed to ensure that complications were prevented; 31% suggested home remedies for hypertension. The majority of the patients were satisfied with the service they received, but 47% complained about long waiting times, 37% felt that the doctor did not examine them adequately, and 15.5% reported that insufficient medication was provided when filling prescriptions. Urine and eye tests had been conducted infrequently during the previous two years. Thirty percent of the patients requested the return of the dedicated hypertension clubs. Conditional logistic regression models identified that patients who expressed the need to make proposals to the clinic staff about their care had better BP control than those who did not., Conclusions: The BP of hypertensive patients is not optimally controlled at this CHC and both non-drug and drug management of hypertension need to be improved. Steps should be taken to help hypertensive patients become more knowledgeable so that they may play more active and compliant roles in their hypertension care. Patients also suggested that dedicated hypertension clubs be reinstituted at the CHCs.

Purpose: Malnutrition, presenting as obesity in women and under-nutrition in children, is a prevalent problem in the squatter communities of Cape Town. Food habits are determined by a complex matrix of economic, social and cultural factors which need to be understood by health professionals prior to the implementation of strategies to improve the nutritional status of this community. This qualitative study is designed to explore the perceptions of overweight black women in Cape Town, with underweight infants, about the culturally acceptable body size for women and children., Method: Qualitative in-depth interviews were conducted with 10 overweight black women who were resident in the metropolitan area of Khayelitsha in Cape Town. A snowballing technique was utilised to select the key informants, all of whom were mothers of underweight infants. The interviews were conducted in Xhosa and recorded, with the permission of participants, onto tape. They were then transcribed and translated into English. The transcripts were coded and analysed by two researchers who worked independently to ensure content validity., Results: The informants came from disadvantaged communities in which food was highly valued as a result of the fact that food security was not assured. The concept of an individual voluntarily regulating the intake of nutrients when food did become available, appeared unacceptable to the informants. It was not clear from the interviews how the participants perceived their normal or "desired" body weight. Increased body mass was regarded as a token of well-being in that marital harmony was perceived to be reflected in increased body weight. Overweight children were regarded as reflecting health as it was associated with sufficient food supply and intake., Conclusions: Although women expressed the desire to loose some excess weight for practical reasons, there was no negative social pressure to motivate this. The attitudes recorded from this qualitative research project suggest cultural perceptions of excess body weight that will complicate the design of effective health promotion strategies to normalise and maintain ideal body weight in this group of African women.

Study Objective: To examine the relation between birth weight and blood pressure at 5 years in a cohort of South African children., Design: Prospective cohort study., Participants: 849 five year old children., Setting: Soweto, a sprawling urban area close to Johannesburg, South Africa, which was a designated residential area for people classified as "black" under apartheid legislation., Main Results: Systolic blood pressure at 5 years was inversely related to birthweight (r = -0.05, p = 0.0007), independent of current weight, height, gestational age, maternal age or socioeconomic status at 5 years. There was no relation between birth weight and diastolic blood pressure. After adjusting for current weight and height, there was a mean decline in systolic blood pressure of 3.4 mm Hg (95% confidence intervals 1.4, 5.3 mm Hg) for every 1000 g increase in birth weight., Conclusions: These data from a disadvantaged urbanised community in Southern Africa extend the reported observations of an inverse relation between birth weight and systolic blood pressure. The study adds to the evidence that influences in fetal life and early childhood influence systolic blood pressure. Further research is required to assess whether efforts to reduce the incidence of low birthweight babies will attenuate the prevalence of hypertension in future generations.

Objectives: The study aimed to describe the treatment status of hypertensive patients and the prescribing patterns of private medical practitioners treating medical aid scheme patients with hypertension., Method: Data on hypertensive patients belonging to medical aid schemes were provided to the drug utilisation review consultancy, Quality Health Services (QHS), by private medical practitioners. The data were computerised and included the age and gender of the patient, the diastolic and systolic blood pressure (BP), the medication prescribed for the condition and the qualifications of the reporting doctor. All the prescribed drugs were categorised into 12 drug classes and combination preparations had each constituent categorised. The level of BP allowed the degree of BP control to be described as controlled (< 140/90 mmHg), borderline (140/90-< 160/95 mmHg) and uncontrolled (> or = 160/95 mmHg)., Results: Included in the study were 11,696 hypertensive patients (46.3% male and 53.7% female) and the 3,503 doctors who cared for them. The systolic BP showed an age-related increase, but the diastolic BP did not. The level of BP control was high, with less than a quarter of patients having uncontrolled hypertension. The most frequently prescribed drug class was angiotensin-converting enzyme (ACE) inhibitors (32.2%). Beta-blockers accounted for 20.8% and calcium antagonists for 14% of all prescriptions. Thiazide and thiazide-like diuretics on their own accounted for only 7.8% of prescriptions. However, a further 13.8% of prescriptions contained this class of diuretics in combination with other drug classes. Diuretics of all classes taken on their own or in combination were used by 33.9% of patients., Conclusions: Good levels of hypertension control were reported for hypertensive patients by their private practitioners. Almost half of all prescriptions were for the newer and more costly antihypertensive drugs (ACE inhibitors and calcium antagonists), although their effectiveness in reducing long-term complications of hypertension is still unproven. Furthermore, these prescribing patterns do not conform to those recommended by the Southern African Hypertension Society's hypertension management guidelines.

Background: This paper reports data on the detection and management of hypercholesterolaemia in patients attending general practitioners in private practice in South Africa., Methods: The frequency of cholesterol testing and the level at which active therapeutic intervention occurred at medical practices were monitored over a 2-year period. A sample of 200 medical practitioners was selected from private practices in major cities. Data on patients seen by the selected doctors during a 5-day monitoring period were recorded on a standardised form., Results: 12,842 patients were seen by the 200 private practice GPs. More men (18.7%) than women (10.4%) had coronary heart disease (CHD), and their mean total cholesterol (TC) levels were 5.9 mmol/l and 6.0 mmol/l, respectively. Only 3.1% of the patients were reported to have familial hypercholesterolaemia (FH) and 12.8% were reported to have a family history of CHD. Reported smoking rates were exceptionally high (77.5% of women and 64.4% of men). The most commonly prescribed group of lipid-lowering agents was HMG-CoA reductase inhibitors., Conclusions: Inadequate management of hypercholesterolaemia leaves many patients with a high risk of CHD mortality in South Africa. Appropriately investigated patients with hypercholesterolaemia should receive treatment to reduce cardiovascular disease using more effective TC control programmes than are currently used in South Africa.

Objective: To describe the distribution of plasma fibrinogen and relationships with other risk factors for coronary heart disease (CHD) and stroke in the black population of the Cape Peninsula., Design: A cross-sectional survey of a stratified proportional sample of randomly selected black men and women., Setting: Households in Gugulethu, Langa, Nyanga, New Crossroads, KTC, Old Crossroads and Khayelitsha in the Cape Peninsula, South Africa., Subjects: One subject per household (352 men and 447 women), aged 15-64 years, voluntarily participated. Visitors, pregnant, lactating, ill, mentally retarded and intoxicated subjects were excluded., Results: Mean fibrinogen (thrombin time coagulation method) of men and women were higher than published data for Europeans but slightly lower than values of black Americans. Women aged 45-54 years had the highest level (3.13+/-0.89 g l(-1)) and men aged 15-24 years had the lowest (2.13+/-0.88 g l(-1)). Fifteen per cent of the men and 12% of the women had a level greater than 1 standard deviation of the mean for their age group. Univariate and multivariate analyses revealed significant (P<0.05) positive correlations of fibrinogen with smoking habit, age, body mass index (BMI), total and low-density lipoprotein (LDL) cholesterol, triglycerides, blood pressure and white blood cell count, and significant negative correlations with high-density lipoprotein (HDL) cholesterol, gamma glutamyl transferase (GGT), serum iron and ferritin. The correlations with BMI, serum lipoproteins, iron, ferritin, and GGT suggest that nutritional status and therefore diet influences plasma fibrinogen., Conclusion: Relatively high fibrinogen levels, tending to cluster with other, including diet-related, risk factors for CHD and stroke, were observed in black South Africans. It is suggested that fibrinogen may contribute to the high stroke incidence of this population group.

This study describes the anthropometry of an urban black population living in the Cape Peninsula, South Africa. A random sample of 986 selected adults aged 15-64 years and 163 children aged three to six years, included data on heights, weights, and mid-upper arm circumferences and calculation of the body mass index (BMI). The mean height of men was 168.3 cm and that of women 158.3 cm. Mean weight, BMI and mid-upper arm circumference for men were 66.2 kg, 23.4 and 28.1 cm and for women 69.8 kg, 27.8 and 30.6 cm respectively. The prevalence of underweight in men (BMI < 20) was 19% and in women (BMI < 19) 3.7%; 22% of the men were overweight (BMI > or = 25) and 7.9% obese (BMI > or = 30), while 36.4% of women were overweight (BMI > or = 24) and 34.4% obese (BMI > or = 30). More than half of the women above the age of 35 years were obese. Anthropometry of the three to six year old children was calculated for stunting, wasting and underweight, expressed in terms of the National Centre for Health Statistics standards, and revealed co-existing evidence of growth retardation and wasting with emergent obesity. These findings suggest that a part of this community, who may have been nutritionally deprived during childhood, has moved from undernutrition to extreme overnutrition without having achieved optimal nutritional status. Complexities that need to be considered when planning strategies to address malnutrition in the black South African population are identified.

Background: After 4 years a coronary heart disease risk factor intervention programme produced equally large and significantly reduced risk profiles in two intervention towns compared with a control town. Intervention effects through community participation were assessed after cessation of the active intervention programme. The impact of secular trends was assessed in the control town and in two previously unstudied towns., Methods: Cross-sectional surveys were done in a random sample of 1620 participants aged 15-64 years in the three original towns 12 years after the initial quasi-experimental study. Two years later 327 subjects, aged 35-44 years, were studied in the original control town and in two non-intervention towns. Risk factor knowledge, smoking and medical histories were determined by questionnaire. Blood pressure, anthropometry and blood lipids were recorded. Data were compared across towns, and with previous surveys., Results: At 12 years the low intensity intervention town maintained a significantly better risk factor profile than the control town, while the high intensity intervention town now matched the control town. No differences in risk factor profiles were found between the control town and the two new towns. Deaths from coronary heart disease and strokes showed a downward trend in the study area., Conclusions: Outcome suggests large ongoing secular trends during the study could have overtaken the intervention effects in the high intensity town, but not in the low intensity intervention town, which showed an advantage over the control town. These results support the effectiveness of media-based, long term health promotion strategies to reduce cardiovascular disease risk profiles.

Mutation analysis of genomic DNA samples obtained from seven unrelated South African Indians with familial hypercholesterolaemia (FH) revealed two novel and two recurrent missense mutations in the low density lipoprotein receptor (LDLR) gene. The novel mutations are transversions of C to G and A to T at nucleotide positions 1215 (N384K) and 2356 (S765C), respectively. The known mutations were detected in CpG dinucleotides at bases 661 and 682, respectively, in the mutation-rich exon 4 of the LDLR gene. Mutation D200Y was found in a single FH family, while mutation E207K was detected in two apparently unrelated Indian families on a new mutual haplotype. Analysis of published mutations including our new data has shown that more than 50% of the different LDLR gene mutations identified to date in South African Indians occur at CpG hotspots.

Background: Men and women have experienced differing patterns of urbanization. Men spent more time in the city as migrant labourers, which could be attributed to the influx control legislation during the apartheid years., Objective: To investigate urban exposure among black people of the Cape Peninsula, South Africa, in relation to unhealthy lifestyles and the risk factors for chronic diseases of lifestyle., Methods: Blood pressure, height, weight and serum cholesterol were measured in a random sample of 986 persons, aged 15-64 years. Sociodemographic details, urban exposure, dietary intake patterns and personal habits were elicited by questionnaire. An urbanization index (percentage of life spent in a city), the dietary Keys score and body mass index were calculated. Linear regression modelling for cholesterol and hypertension, and multiple correspondence analysis for risk factors and demographic characteristics were performed., Results: The degree of urbanization had no effect on total serum cholesterol concentrations, which were very low compared with other groups in South Africa. Hypertension was independently related to age, obesity and the degree of urbanization. Smoking patterns were influenced by the degree of urbanization in women only. Correspondence analysis identified groups with clusters of risk factors: formal housing-westernized diet-highly urbanized; male-normal weight-increased exercise-alcohol-smoking; female-obesity-non-smoking; and hypertension-ageing., Conclusions: Those who spent larger proportions of their lives in an urban setting tended to have unhealthier lifestyles and higher risk for chronic diseases lifestyle compared with their less urbanized counterparts. Groups to whom intervention should be targeted were also identified.

Aim: To estimate the exposure to active and passive smoking of pregnant women in South Africa and to determine their knowledge and behaviour with regard to smoking during pregnancy., Methods: A questionnaire was completed by pregnant women attending antenatal services in four South African cities. Questions were asked about smoking status, beliefs on the health effects of tobacco smoke during pregnancy, exposure to passive smoking and behavioural changes with regard to smoking during pregnancy. Women from different ethnic groups and social classes participated., Results: The study population was 394 pregnant women. Of these 42% were black, 29% coloured and 10% Indian women, who used public antenatal services, and 19% were pregnant women (ethnicity unspecified) who attended private obstetric practices. Of the coloured women, 47% smoked; for the black and Indian women and those who attended a private practice, the smoking rates were 4%, 3% and 28%, respectively. Approximately 90% of the pregnant women knew it was unhealthy to smoke during pregnancy. Most women who smoked stopped or reduced tobacco use during their pregnancy. Of the pregnant women, 70% lived with at least one smoker in the house., Conclusions: Few black and Indian pregnant women in South Africa smoke, while coloured pregnant women smoke heavily. Quitting programmes should be targeted at them when they attend antenatal services. Pregnant women and their families should be alerted to the impact of environmental tobacco smoke, since so many are passive smokers during pregnancy.

Hypertension prevalence, treatment status and factors relating to high blood pressure were determined in an urban black community of the Cape Peninsula, South Africa. A study population of 986 subjects aged 15-64 years was randomly selected. Blood pressure, height, weight and serum cholesterol levels were measured, while demographic information, personal and family history relating to hypertension and attendance of health services were determined by questionnaire. Overall 9.2% of males and 12.9% of females were hypertensive according to WHO criteria. Blood pressures between 160/95 and 140/90 mmHg were found in 10% of males and 10.5% of females. The treatment status of hypertensives showed that 24.3% had a blood pressure below 160/95 mmHg, and 16% below 140/90 mmHg. Hypertensives used more alcohol and were more overweight than normotensives. Multiple logistic regression revealed that hypertension was independently related to age, being overweight and more urbanised. The degree of urbanisation also predicted to what extent hypertension prevalence increases with age. This black population had low hypertension rates compared with other similar groups in South Africa. These data suggest that as rural blacks increasingly undergo urbanisation, hypertension prevalence increases. Necessary diagnostic and treatment regimens and hypertension services are not yet in place in the South African health services, and need to be established.

We have determined the prevalence of familial hypercholesterolaemia (FH) in a rural Afrikaner community by means of direct DNA screening for three founder-related Afrikaner low density lipoprotein (LDL) receptor gene mutations. A random sample of 1612 persons, aged 15-64 years, was selected as a subsample of 4583 subjects from an Afrikaner community living in the south-western Cape, South Africa. Participants who had a total serum cholesterol (TC) in the high TC category as defined in the consensus recommendations by the Southern African Heart Foundation, were screened for three founder-related LDL receptor gene mutations, causing FH in 90% of Afrikaners. Of the subsample, 201 participants (12.5%) had TC levels above the 80th percentile. In this group the combined prevalence of the three common Afrikaner LDL receptor gene defects (D206E, FH Afrikaner-1; V408M, FH Afrikaner-2; D154N, FH Afrikaner-3) was calculated as 1: 83. When taking into account the reported background prevalence of other FH gene defects of 1:500 in this community, their overall prevalence of FH was estimated to be 1:72. The significant differences found between the FH patients and other high risk patients with raised cholesterol levels were higher TC and LDL cholesterol levels and lower high density lipoprotein cholesterol levels in FH patients. The treatment status of the molecularly identified FH patients and other hypercholesterolaemic persons suggests that this condition is inadequately diagnosed and poorly managed in this study population. An extrapolation to the entire South African population suggests that there are about 112000 FH patients in the country who are under-diagnosed as a group and therefore not receiving the care that would help to reduce the burden of FH-associated ischaemic heart disease in South Africa.