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The coloured population of the Cape Peninsula has been identified as having a high prevalence of risk factors for coronary heart disease (CHO), notably hypertension, cigarette smoking and hypercholesterolaemia. The need for an appropriate and effective CHO intervention programme, directed at the population as a whole, has become urgent. Three central problem areas relating to hypertension control - diagnosis, management and compliance - will have to be addressed. Hypertension was underdiagnosed among men, particularly those aged 25 - 44 years. Apart from educating this group regarding the need to have their blood pressure measured, detection programmes are therefore needed at the workplace to improve hypertension diagnosis. Inadequate management of hypertension was commonest in women aged over 45 years. Compliance with hypertension treatment regimens was poor in all men as well as in both sexes belonging to the lower socio-economic strata. Establishing easily accessible blood pressure stations for monitoring blood pressure and educating hypertensives regarding their condition could lead to improved management and compliance. Coloureds were found to smoke heavily, and the women had the highest smoking prevalence of all South African women. Furthermore, the age of onset of smoking is decreasing among coloured children. A general anti-smoking campaign directed at all South Africans is necessary to control smoking. Anti-smoking education programmes at primary school level are of particular importance to prevent the onset of the habit. More than 70% of coloureds had a serum cholesterol level imparting CHO risk, few followed a prudent diet and their knowledge of the prudent diet was poor. Health education programmes to promote the prudent diet are required. The need for. appropriately trained health educators in schools, workplaces, health clinics and all hospitals has been identified. An extensive health education service should be expanded by including the use 'of mass media, particularly television, to promote health.S Afr Med J 1990; 78: 78-81

Study of a sample of 976 randomly selected coloured persons 15 - 64 years of age living in the Cape Peninsula included measurement of height, weight and mid-arm circumference and calculation of the body mass index (BMI). The mean height of the men was 167,6 cm and that of the women 156 cm. Mean weight, BMI and mid-arm circumference for men were 65,9 kg, 23,4 and 27,5 cm respectively and those for women 65,8 kg, 27,1 and 28,9 cm respectively. The prevalence of underweight for men (BMI < 20) was 23,6% and for women (BMI < 19) 9,8%; 17,7% of men were overweight (BMI ≥ 25) and 3,7% obese (BMI ≥ 30), while 35,2% of women were overweight (BMI ≥ 24) and 18,8% obese. Overweight and obesity were more common among the older coloured women than among a group of South African white women of the same age. Obese women in the age group 35 - 44 years were 4,8 times more likely to be hypertensive than women of normal weight in the same age group (odds ratio; 95% confidence interval 2,2 • 4). Older women did not show this association. There were too few obese men to analyse in this manner. Many of the obese participants did not see themselves as obese. Only 19,7% of men and 45,2% of women had attempted to lose weight during the year preceding the study, in many cases using methods known to be ineffective. The coloureds of the Cape Peninsula were found to be a population with shorter stature than South African white and American populations. Some young participants of both sexes and some older men were underweight, while among older women there was a high prevalence of overweight and obesity. The findings may suggest previous undernutrition in both sexes, with a marked tendency to current overnutrition in adult females.S Afr Med J 1990; 78: 68-72.

The health-related behaviour of the Cape Peninsula coloured population, which has been shown to have an adverse coronary heart disease (CHO) risk factor profile, is reported. Private medical services were used most often by participants: 54,1% and 51,6% of males and females respectively had made use of these services during the preceding year. Only 17,9% and 21,8% of males and females respectively had attended day hospitals during the year. Blood pressures were measured in 43,8% and 57,1% of male and female participants respectively during the year preceding the study. The results indicated the need for the measurement of blood pressure to determine the true prevalence of hypertension, since patient reporting of the condition was inaccurate. Attempts to give up smoking had been made by 44,4% of male and 47,1% of female smokers. About 75% of the participants were found to have hypercholesterolaemia, yet their knowledge of the prudent diet was poor and few reported appropriate dietary modifications to protect against CHO. Frequent reporting of hypercholesterolaemia, hypertension and constipation by the study population highlights the need for dietary education. Mortality rates (MRs) for CHO and cerebrovascular disease (CVO) for the coloured and the white populations were compared. In all age groups white males had higher MRs for CHO than coloured males, while coloured females older than 34 years had higher rates than their white counterparts. The coloured population had MRs for CVO that were higher than those of whites.S Afr Med J 1990; 78: 73-77

A cross-sectional study of 976 coloured subjects aged 15 -64 years identified a population consuming a typical Western diet. Nutrient intake, determined by the 24-hour dietary recall method, reflected a diet high in fat (37% of total energy intake) and animal protein and a polyunsaturated/saturated fatly acid ratio of 0,85. Only 32,2% of men and 27,5% of women consumed a prudent diet (Keys score < 28). The influence of this Western diet on serum total cholesterol (TC) levels was seen to be marked whe'n participants with a high risk of developing coronary heart disease (CHD) were compared with those with a TC level putting them at low risk; the former consumed significantly more saturated fat and had a higher mean Keys score. Multiple linear regression analysis on TC levels of men identified six variables that explained 26,9% of the variation of TC. These were body mass index, age, the inverse of the polyunsaturated fat intake, saturated fat intake, polyunsaturated/saturated fat ratio and cholesterol intake. For women only three variables (age, the inverse of the polyunsaturated/saturated fat ratio, and body mass index) explained 30,2% of the variation of TC. Promotion of the prudent diet to lower TC levels of the coloured population of the Cape Peninsula is an increasingly urgent priority.S Afr Med J 1990; 78: 63-67.

The objective of the hypertension programme of the Coronary Risk Factor Study (CORlS) was to evaluate the effectiveness of the first 4 years of community-based intervention. The hypertension intervention model comprised a blood pressure station where the whole population was screened for hypertension, non-drug management was provided and hypertensives were monitored after referral to general practitioners for drug therapy. Two levels of intervention were maintained: in the high-intensity intervention town (N =2 278) hypertensives were actively followed up, and in the low-intensity intervention town (N =2 620) no active follow-up procedure existed. A third town acted as control (N= 2 290).In the cohort which was hypertensive at baseline, the net decreases in systolic blood pressure (mean ± SE) after correction for changes in the control town were 0,5 ± 2,2 mmHg (men) and 4,5 ± 2,2 mmHg (women) in the low-intensity intervention town, and 5,6 ± 2,3 mmHg (men) and 7,5 ± 2,2 mmHg (women) in the high-intensity intervention town. The net decrease in diastolic blood pressure was 3,4 ± 1,2 mmHg (men) and 4,4 ± 1,1 mmHg (women) in the low-intensity intervention town, and 6,1 ± 1,2 mmHg (men) and 5,9 ± 1,1 mmHg (women) in the high-intensity intervention town. These reductions were statistically significant with one exception. The changes in the total population in the 3 communities after 4 years of intervention were similar to those found in the hypertensive cohort.Decreases in mean blood pressure were accompanied by marked increases in the proportion of hypertensives on drug treatment and the proportion under control (

A cross-sectional study of risk factors for ischaemic heart disease (IHO) in a random sample of 986 black people aged 15 - 64 years living in the Cape Peninsula revealed a population at lower risk for IHO than other South Africans. Blood pressures of 140/95 mmHg or above were found in 14,4% of males and 13,7% of females. Fifty-two per cent of males and 8,4% of females smoked, while 16,5% of males and 25,8% of females had a total cholesterol (TC) level imparting risk for developing IHO. In this population the TC level is not a good surrogate measure for low-density lipoprotein cholesterol because of the high level of high-density lipoprotein cholesterol (HOLC) found in this population. A protective HOLC/TC ratio of 20% was found in 96% of males and 96,1% of females. When considering the three major reversible IHO risk factors at a high level of risk, 30,8% of males and 12,5% of females had at least one such a risk factor. The population was frequently exposed to the media, with 80% listening to the radio every day and 55% watching television at least once a week. This suggests that a healthy lifestyle could be promoted successfully by means of these media. In addition, schools should promote a healthy lifestyle and the prevention of chronic degenerative diseases should be incorporated into the evolving primary health care services in South Africa.

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.

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Objective. To determine and compare the prevalence of ischaemic heart disease (IHD) risk factors in a rural and an urban black population.Design. A survey to determine the prevalence of hypertension, diabetes mellitus, smoking, obesity, central obesity and dyslipidaemia in black subjects 25 years and older.Setting. The indigenous black populations of QwaQwa and Mangaung.Participants. A random sample of 950 households was selected from each area. From each household an unrelated male and/or female subject was selected in a standardised way. From QwaQwa 853 subjects (279 men and 574 women) and from Mangaung 758 subjects (290 men and 468 women) participated in the study. The response rate was 68% and 62% respectively for QwaQwa and Mangaung.Main outcome measures. Few urban-rural differences in the prevalence of IHD risk factors were found in this study. A low prevalence of clustering of major IHD risk factors was noted.Results. The age- and sex-adjusted prevalences of hypertension were 29% in QwaQwa and 30,3% in Mangaung. Oiabetes was present in 4,8% of the QwaQwa sample and 6% of the Mangaung sample. The prevalence of heavy smoking in the Mangaung sample was almost double that of the QwaQwa sample and mostly confined to men. High-risk hypercholesterolaemia was present in 12,5% of QwaQwa and 6% of Mangaung men in the 25 - 34-year age group. The corresponding figures for moderate-risk hypercholesterolaemia were 34% and 44,8% and both levels of risk declined with increasing age. The mean body mass index of women in both samples exceeded 25 kg/m2.Conclusion. All the elements for a potential epidemic of atherosclerotic cardiovascular disease are present in the study populations. The similarity of findings in the two samples may be indicative of the advanced stage of urbanisation and westernisation of the rural group. It is alarming that subjects in the younger age groups tendeo to have the highest prevalences of moderate and even high-risk hypercholesterolaemia.

Objectives. To describe the pattern of prescribing for hypertension at a community health centre (CHC) and to evaluate the impact of introducing treatment guidelines and restricting availability of less cost-effective antihypertensive drugs on prescribing patterns, costs of drug treatment and blood pressure (BP) control.Design. Before/after intervention study.Setting. Medium-sized CHC in the Cape Flats area of Cape Town.Subjects. 1 084 hypertensive patients attending the CHC, who had at least two prescriptions for antihypertensive drugs during a 1-year period starting on 1 January 1992. Interventions. 1. Implementation of stepped-care guidelines for hypertension, specifying treatment with more cost-effective drugs and minimising drug treatment. 2. Reducing availability for routine prescribing by CHC doctors of 10 less cost-effective antihypertensive drugs or drug combinations.Outcome measures. 1. Mean number of drugs prescribed per patient. 2. Proportion of prescriptions for: each major class of antihypertensive drug; restricted availability and freely prescribable drugs; and more and less cost-effective drugs. 3. Mean monthly cost of drugs prescribed per patient. 4. Mean blood pressure and proportion of BP readings controlled (

Objectives. To describe the demographic profile of hypertensive patients and the quality of care for hypertension at a Cape Town community health centre (CHC).Design. Prospective, descriptive study.Setting and subjects. Medium-sized CHC, attended by 1098 hypertensive patients during a 1-year period from 1 January 1992.Outcome measures. Default rate - proportion of due visits not attended. Loss to follow-up - proportion of patients persistently defaulting or not responding to recall. Frequency of blood pressure measurement - per 12 due visits. Compliance - proportion of patients collecting ≥ 75% of antihypertensive drugs. Blood pressure control - mean blood pressure of aggregated readings; and proportion controlled (

Background. 1bis 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 citie;. Data on patients seen by the selected doctors during a 5-day monitoring period were recorded on a standardised form.Results. 12842 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 hypercholesterol-· aemia 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 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.

To assess the evidence from systematic reviews on the effect on morbidity and mortality of blanket screening for hypertension or diabetes mellitus compared with targeted, opportunistic or no screening, we searched for relevant systematic reviews and conducted duplicate study selection, data extraction and quality appraisal. Results were summarised narratively. We included two completed reviews of moderate quality and one ongoing Cochrane review. In one completed review, general health checks had no effect on total morbidity or mortality or on healthcare services compared with no health checks. In the other, intensive hypertension screening methods were ineffective in increasing screening uptake or detecting new cases compared with less intensive methods. Both reviews included studies in high-income settings. There is insufficient evidence from currently available systematic reviews to confirm a beneficial effect of blanket screening for hypertension and/or diabetes compared with other types of screening methods in low- and middle-income settings. Scarce resources are being mobilised to implement mass screening intervention for diabetes and hypertension without adequate evidence of its effects. A systematic review is needed to assess clinical effectiveness, cost-effectiveness and overall impact on the health system of screening strategies, especially in low- and middle-income settings such as exist in South Africa. Robust evaluation of these outcomes would then be necessary to inform secondary prevention strategies.

Increased salt intake leads to an increase in blood pressure and decreased sodium intake relative to the usual or increased intake results in lowered blood pressure in adults, with or without hypertension. Blood pressure is a strong proxy indicator for the risk of cardiovascular disease, coronary heart disease and strokes. Hypertension is estimated to have caused 9% of all deaths in South Africa in 2000. In 2008, 42% of men and 34% of women aged 35-44 years, and 60% of men and 50% of women aged 45-54 years, were hypertensive. More than 70% of both men and women older than 65 years of age were hypertensive in 2008. Multilevel and multisectorial strategies are required to lower salt intake at population level, including the legislation of food supply, clearer labelling and signposting of food packaging, and improved consumer education on behavioural change regarding salt usage practices. A comprehensive national strategy that focuses on salt reduction is needed to reduce national blood pressure levels in the future. Legislating the levels of salt in processed food is only one part of this national strategy. All health professionals and educators should also provide appropriate nutritional recommendations that will educate, motivate and enable consumers to change their nutritional behaviour to reduce salt intake to less than 5 g per day, as recommended. The aim of this review is to revise the current food-based dietary guideline for salt, the implementation of which would contribute to lowering population salt intake, and blood pressure and cardiovascular disease, in South Africa.

INTRODUCTION: Since peaking in the early 1990s in South Africa, tobacco use has declined significantly. The reduction has been attributed to the government's comprehensive tobacco control policies that were introduced at the time. OBJECTIVE: To assess the pattern of tobacco use in the South African Demographic and Health Surveys of 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%; it decreased among men 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 among men in 2003. Higher income and education were associated with low prevalence of smoking, while living in urban areas was associated with higher rates. Black men and women smoked significantly less than other population groups. CONCLUSION: Despite decreased smoking rates in some subgroups, a lapse exists in the efforts to reduce tobacco use, as smoking rates have remained unchanged among women, and also among young adults aged 15 - 24 years.

No Abstract JEMDSA Vol. 13 (2) 2008: pp. 64-71

Objectives. To estimate the burden of disease attributable to high blood pressure (BP) in adults aged 30 years and older in South Africa in 2000. Design. 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 simulationmodelling techniques were used for uncertainty analysis. Setting. South Africa. Subjects. Adults aged 30 years and older. Outcome measures. Mortality and disability-adjusted life years (DALYs) from ischaemic heart disease (IHD), stroke, hypertensive disease and other cardiovascular disease (CVD). Results. 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). Conclusions. 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. South African Medical Journal Vol. 97 (8) Part 2 2007: pp. 692-698

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. South African Medical Journal Vol. 97 (8) Part 2 2007: pp. 708-715

No Abstract. South African Medical Journal Vol. 97 (8) Part 2 2007: pp. 643-649