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Jamison DT, Feachem RG, Makgoba MW, et al., editors. Disease and Mortality in Sub-Saharan Africa. 2nd edition. Washington (DC): The International Bank for Reconstruction and Development / The World Bank; 2006.

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Disease and Mortality in Sub-Saharan Africa. 2nd edition.

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Chapter 18Lifestyle and Related Risk Factors for Chronic Diseases

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Chronic diseases, often referred to as noncommunicable diseases (NCDs), usually emerge in middle age after long exposure to an unhealthy lifestyle involving tobacco use, a lack of regular physical activity, and consumption of diets rich in highly saturated fats, sugars, and salt, typified by "fast foods." This lifestyle results in higher levels of risk factors, such as hypertension, dyslipidemia, diabetes, and obesity that act independently and synergistically. The risk factors are frequently undiagnosed or inadequately managed in health services designed to treat acute conditions.

Chronic conditions are frequently incorrectly considered to have limited impact on the burden of disease in Sub-Saharan Africa, because of the known high relevance of the infectious diseases. Nevertheless, these diseases occur in younger age groups more commonly in Sub-Saharan Africa than in the developed countries and are at least as common in the poor sector of society as in the more affluent.

The current burden of chronic diseases reflects the cumulative effects of unhealthy lifestyles and the resulting risk factors over the life span of people. Some of these influences are present from before a child is born.

Antenatal Influences on the Emergence of Risk Factors for Chronic Diseases

The fetal origins of adult chronic diseases play a particularly important role in Sub-Saharan Africa countries. The adequacy of the mother's nutrition before and during pregnancy is the first key component in determining the infant's birthweight. The latter in its own right is associated with the emergence of chronic disease risk factors in these children (Barker 1993, 1994). In The Gambia, an inverse relationship was found between the weight gain of women in the last trimester of pregnancy and the blood pressure of their children at age eight years (Margetts et al. 1991).

Another critical factor during pregnancy is cigarette smoking, which results in high rates of low birthweight (LBW) babies and other complications in pregnancy. This association has been reported in some Sub-Saharan Africa countries (Odendaal, Van Schie, and De Jeu 2001; K. Steyn, unpublished data). Fortunately, smoking tobacco products during pregnancy or the reproductive years is not a common phenomenon in African women, particularly if they still live according to their traditional lifestyles. However, surveys of women who progressively adopt Western lifestyles show that smoking during pregnancy or during the reproductive years is becoming far more common (Steyn et al. 1994; Steyn et al. 1997).

LBW is common in Sub-Saharan Africa countries. For example, Kinabo, Kissawke, and Msuya (1997) reviewed the birth records of 40,595 full-term live singleton infants and found a 15.4 percent prevalence of birthweight below 2,500 grams. In a five-year randomized control trial of maternal supplementation in a rural primary health care setting in The Gambia, 15.9 percent of LBW babies were born in the control group. The intervention group received high-energy groundnut biscuits for about the last 20 weeks of their pregnancy, and that significantly reduced the LBW rate to 10.7 percent. These data highlight the need to ensure adequate nutrition for women in Sub-Saharan Africa during pregnancy (Ceesay et al. 1997).

Levitt, Steyn, De Wet, and colleagues (1999) showed that LBW predicted systolic blood pressure level at age five years in the children in Soweto, South Africa. The data show that children who had a LBW and had gained the most weight during the five years since birth had the highest systolic blood pressure. Those children who were of normal weight at birth and maintained a normal weight had the lowest systolic blood pressure (Levitt, Steyn, De Wet, et al. 1999). A glucose tolerance test done on these children when they were seven years old showed that LBW in conjunction with rapid childhood weight gain, especially if there was a large gain of subcutaneous fat, produced poor glucose tolerance (Crowther et al. 1998).

A study by Longo-Mbenza and colleagues (1999) in Kinshasa, Democratic Republic of Congo, of 2,409 schoolchildren age 5 to 16 years also showed a significant inverse relationship between LBW (less than 2,500 grams) and blood pressure, as well as heart rate. In Cape Town, South Africa, Levitt, Steyn, Lambert, and colleagues (1999) found the same relationship in adults age 20 years who had LBW. These young adults also had impaired glucose tolerance, as well as increased plasma cortisol and cortisol axis activation, compared with young adults who had a birthweight of 2,500 grams or more (Levitt et al. 2000; Longo-Mbenza et al. 1999).

The association between poor intrauterine growth because of inadequate nutrition and smoking tobacco during pregnancy, resulting in LBW and increased NCD risk in children in Sub-Saharan Africa, could possibly increase in the twenty-first century. At the beginning of this century most of the Sub-Saharan Africa countries were in the grip of serious food shortages as well as unopposed promotion of tobacco products targeting women and youth. This situation led to more starvation and more smoking during pregnancy and thus to the birth of more LBW babies in these countries.

Tobacco Use

As tobacco-control activities in the developed world have increased, the tobacco industry has shifted its marketing to middle- and low-income countries. Not only do these countries have fewer formal tobacco-control activities in place, but they also have a much larger population, which can provide future consumers of tobacco products. In Sub-Saharan Africa countries, most people are young and have relatively low levels of education. They rarely receive the necessary health education to allow them to critically evaluate the material provided by the tobacco industry promotions.

The following five countries participated in the global Youth Tobacco Survey: Ghana, Malawi, Nigeria, South Africa, and Zimbabwe (Global Youth Tobacco Survey Collaborative Group 2002). The data from the five Sub-Saharan Africa countries are shown in table 18.1. Although a significant number of youths age 13 to 15 smoked cigarettes, many more used other tobacco products. Relatively few of the youth smoked at home. These data also raise concern about the pattern and impact of tobacco marketing in Sub-Saharan Africa. Overall, more than 10 percent of the youth had been offered free cigarettes by the tobacco industry, and about 40 percent of them thought boys who smoked had more friends. Despite the traditional taboos against smoking by women, about 20 percent thought that those girls who smoked had more friends than those who didn't.

Table 18.1. Exposure to Tobacco Products of Participants, Age 13–15 Years, in the Global Youth Tobacco Survey, 1999–2001.

Table 18.1

Exposure to Tobacco Products of Participants, Age 13–15 Years, in the Global Youth Tobacco Survey, 1999–2001.

More than 60 percent of the youth had seen antismoking media messages, and between one-third and two-thirds had been taught the dangers of smoking at school. Of the youth who smoked, 74 percent and 54 percent in South Africa and Zimbabwe, respectively, had tried to quit in the previous year (Global Youth Tobacco Survey Collaborative Group 2002).

The impact of tobacco marketing on five-year-olds has been shown in children living in Johannesburg and Soweto in the Birth-to-Ten study (Levitt, Steyn, De Wet, et al. 1999). This birth cohort comprised children who were born in 1990, and by the time they were five years old the new political dispensation had been established and the country had a new South African flag. When these children were shown pictures of well-known logos of cigarettes available in South Africa along with that of the new flag and the logos of other well-known South African brands, over 90 percent of the children identified the new flag. This showed clearly that this new South African symbol had been internalized by the age of five years. Therefore, it was of great concern when it was found that between 51 and 76 percent of these children could identify the logos of popular cigarette brands. The highest level of recognition was for the cigarette brand of the company that sponsored the soccer tournament in the previous year. Seven percent of these five-year-old children had experimented with cigarettes at least once (Thea de Wet, unpublished data).

Only 23 of the Sub-Saharan Africa countries had any data on cigarette-use prevalence rates available in 2000, and only a few had data on rates based on adequate national surveys (Corrao et al. 2000). These data are shown in table 18.2.

Table 18.2. Prevalence of Adults Who Smoke Cigarettes, by Country.

Table 18.2

Prevalence of Adults Who Smoke Cigarettes, by Country.

Generally, men smoke much more than women do. With the exception of women in Guinea, Kenya, and Namibia, only 20 percent or fewer of the women smoke. However, these figures probably underestimate tobacco use, as cigarettes are not the only form of tobacco used in Sub-Saharan Africa. A substantial number of people use hand-rolled cigarettes or smoke a pipe, and the use of smokeless tobacco is common in women. In South Africa, Steyn and colleagues (2002) found that 12.6 percent of black women used snuff, a higher rate than the 5.3 percent of black women who smoke regularly. Black women in Cape Town believe that snuff has medicinal value as well as that of pain relief (Marks, Steyn, and Ratheb 2001).

It is traditionally taboo for black women of Sub-Saharan Africa to smoke during their reproductive years. Marks, Steyn, and Ratheb (2001) found that Xhosa women in Cape Town manifested this attitude, as 72 percent of the women participating in the survey thought it disgraceful, shameful, and taboo for them to smoke. The women who smoked did so in private settings or in secret. Almost all women who smoked said they did not smoke in front of their elders or parents.

In their promotion of tobacco products in Sub-Saharan Africa, tobacco companies target women and youth with images of "attractive, successful, upwardly mobile black women." They have thus overwhelmed many of the traditional taboos. This was revealed by Marks, Steyn, and Ratheb (2001), who found in their Cape Town study that 5 percent of nonsmoking black women were found to be pro-smoking in orientation and on the verge of smoking, whereas another 53 percent were found to have only a shallow commitment to not smoking.

It has been reported from South Africa that black women start to smoke at a later age than do women elsewhere in the world (Steyn et al. 2002). The implication is that intervention programs in Sub-Saharan Africa should be targeting women in their reproductive years to prevent the onset of smoking and for smoking cessation programs.

Commercially manufactured cigarettes in Sub-Saharan Africa are characteristically sold singly. It has been estimated that in Nigeria up to 80 percent of cigarettes are sold in singles. Either people cannot afford to buy packs of 20 or they sometimes supplement other forms of tobacco use with manufactured cigarettes (Saloojee 2000).

Saloojee (2000) suggests that Sub-Saharan Africa has the lowest tobacco consumption rates and tobacco-related mortality in the world but that the current trend of tobacco consumption implies that it is only a matter of time before it succumbs to the same pattern of tobacco-related diseases as the rest of the world. Projections suggest that the tobacco epidemic can peak in Sub-Saharan Africa in the middle of this century. Saloojee emphasizes that it is extraordinary to be able to predict an epidemic so far in the future and have the knowledge to prevent it. Price increases are the single most important factor in reducing smoking rates in a country. The price elasticity, defined as the degree to which tobacco consumption decreases with increasing price, is higher in developing countries than in richer countries. Significant price increases for cigarettes and other tobacco products, therefore, would be a major step toward improved tobacco control for Sub-Saharan Africa (Saloojee 1995). Although smuggling may account for up to 50 percent of consumption in some settings and may limit the impact of price increases, economic policies have been effective in limiting tobacco consumption.

Nutrition in Transition

A diet high in fat, particularly saturated fat, low in carbohydrates, fruit, and vegetables, along with a high salt intake leads to the emergence of chronic risk factors. Traditional diets in Sub-Saharan Africa, which are low in fat and high in unrefined carbohydrates, protect people against chronic diseases. The nutrition transition refers to large shifts in the composition and structure of diets (Popkin 2001a). The dietary changes of the nutrition transition involve large increases in the consumption of fat (especially saturated fat) and sugar, marked increases in animal products, and a decline in unrefined cereal and, thus, in fiber intakes (Popkin 2001a, 2001b).

Nutrition patterns in Sub-Saharan Africa countries are influenced by many factors, including individual preference; culture, traditions, and beliefs; and price. However, availability and accessibility are the principal factors that shape dietary patterns (N. P. Steyn, WHO, personal communication). In the Sub-Saharan context, war and internal strife, drought and poor agricultural practices, and rapid urbanization are particularly influential. In addition, multinational food companies market their products aggressively in the region. For example in West Africa, consumption has changed from that of locally produced coarse grains, such as millet and sorghum, to imported wheat and rice (Teklu 1996).

In the black population of Cape Town, it was found that a larger proportion of life spent in the city was associated with an increased consumption of fat and a decrease in carbohydrates (figure 18.1). This is reflected in an increased use of dairy produce, meat, fat, and nonbasic food items and a decreased intake of cereals (Bourne, Lambert, and Steyn 2002).

Figure 18.1

Figure 18.1

Fat and Carbohydrate Intake as Functions of Proportion of Life Spent in a City Source: Bourne, Lambert, and Steyn 2002.

An examination of food balance sheets, based on the amount of food sold in South Africa indicates that per capita available fat consumption increased by 27 percent between 1993 and 1999 (figure 18.2). This increase was accompanied by a decrease in carbohydrate consumption.

Figure 18.2

Figure 18.2

Macronutrient Intakes in South Africans, per Capita, 1993 and 1999 Source: Steyn, Senekal et al. 2000; data extrapolated from food balance sheets.

An enigma in the proposed relationship of a diet high in cholesterol and fat, but with little fruit and vegetables, and raised blood cholesterol levels was reported for the pastoral Masai in Tanzania. Although their traditional diet was high in cholesterol and fat from whole milk, blood, and meat, and included little green vegetables or fruit, they maintained low serum cholesterol levels (Gibney and Burstyn 1980). It was suggested that this unexpected relationship could be explained by the cholesterol-lowering effect of the high levels of fermented milk consumed by the Masai and the substantial amounts of saponins and phenolic compound in the plant dietary additives used by them (Johns et al. 1999; St-Onge, Farnworth, and Jones 2000). Unfortunately, these protective dietary practices have declined and new dietary changes have been observed in the pastoral Masai; consequently there has been a significant increase in their serum total cholesterol levels (McCormick and Elmore-Meegan 1992). Not even the physically active Masai of Sub-Saharan Africa could escape the impact of the nutrition transition.

Aerobic Exercise

Adequate physical activity has been shown to have many health-promoting properties and has a direct, independent role in reducing cardiovascular disease mortality (Haskell, Leon, and Caspersen 1992; McBride et al. 1992). Traditionally, it has been thought that a high level of physical exercise could in part explain the low levels of chronic diseases found in Sub-Saharan Africa countries. However, the amounts of physical exercise have been decreasing as a result of the high degree of urbanization that has been occurring across the continent. In urban settings, public transport replaces the traditional pattern of walking long distances, and urban employment usually entails far less physical labor than rural employment or other activities of daily living, such as chopping wood, carrying water, or tilling the fields. In the cities, high crime levels prevent people from moving about freely. In the poorest periurban settings, inhabitants watch television more frequently than their rural counterparts do. Few studies on the physical activity patterns of people in Sub-Saharan Africa have been published.

A study carried out in Cameroon comparing rural with urban people 15 years of age or older clearly illustrated lower rates of physical activity in the urban settings (Sobngwi et al. 2002). Similar differences were found for healthy, elderly people in Nigeria (Ezenwaka et al. 1997). In the urban settings, 62 percent of men and 83 percent of women age 55 years or older led a sedentary lifestyle, whereas this was the case for only 22 percent of men and 50 percent of women in the rural areas. In Nigeria it was also found that civil servants with high seniority had lower levels of physical activity than their junior counterparts, suggesting that upward social mobility was associated with less physical activity (Forrest et al. 2001).

Many studies across Sub-Saharan Africa have revealed the impact of a sedentary lifestyle on emerging NCD risk factors. The physical activity of the Nigerian civil servants studied by Forrest and colleagues (2001) was mostly attributed to occupational activities. Low levels of physical activity were correlated to weight, body mass index (BMI), waist-to-hip ratio, blood pressure, insulin levels, and total and low-density lipoprotein (LDL) cholesterol in men. Similarly, Sobngwi and colleagues (2002) in Cameroon as well as Aspray and colleagues (2000) in Tanzania concluded that physical inactivity was associated with obesity, diabetes, and hypertension in the people they studied in urban and rural settings in both Cameroon and Tanzania. A qualitative study in Cameroon also found that the reduced physical activity accompanying sedentary occupations in the cities explained the higher rate of obesity observed in people with these sedentary occupations (Treloar et al. 1999). Levitt, Steyn, Lambert, and colleagues (1999) showed an independent association between low levels of physical activity and having type 2 diabetes in a poor, periurban community near Cape Town.

In an interesting three-year prospective study in Senegal, researchers followed the unusually high physical activity level of adolescent girls between the ages of 13 and 15 years; physical activity was measured by accelerometers recording minute-by-minute movements (Benefice and Cames 1999; Benefice, Garnier, and Ndiaye 2001a , 2001b; Garnier and Benefice 2001). The girls were spending a minimum of 3.5 hours per day doing domestic duties, including collecting water and stomping maize. The level of physical activity was higher during the rainy season. During the dry season, some of these adolescent girls were sent to the cities to work as servants. It was found that the adolescents in the city had an even higher physical expenditure than those who stayed at home. However, despite the heavier workload, those in the city had a better nutritional status. These healthy Senegalese girls all had higher physical activity levels than those reported for girls in developed countries.

A health and fitness survey of adolescent schoolchildren age 12 to 18 years in the Western Cape in South Africa conducted by Lambert and colleagues in 2000 found that a high level of fitness was inversely associated with current BMI in both boys and girls. Inactivity, defined as watching television for more than three hours a day, was associated with current BMI and a low fitness level. The use of BMI projection formulas to predict future BMI suggests that 24.5 percent of the females and 12.8 percent of the males will be overweight at the age of 18 years (Lambert et al. 2000).

Two surveys carried out seven years apart in Maputo, Mozambique, of students age 8 to 15 years in the same group of schools, showed a significant increase of mean systolic blood pressure, diastolic blood pressure, and total body fat between the 1992 and the 1999 samples for all ages and for both sexes but no changes in the mean level of cholesterol. These changes of cardiovascular risk factors were attributed to the reductions in physical activity observed concomitantly with changes in nutrition (Damasceno and Prista 2001).

One of the reasons for the small number of published studies on physical activity in Sub-Saharan Africa is the difficulty of measuring it in large epidemiological studies. For such studies researchers have to rely on physical activity questionnaires that must be accurate, valid, and reproducible. Some efforts have been made to develop questionnaires that may be useful for Sub-Saharan Africa countries or that can be shown to be reliable in all regions of the world. Sobngwi and colleagues (2001) clearly showed how necessary this validation process is for the use of physical activity questionnaires with people in Sub-Saharan Africa, as study participants' self-ranking of their physical activity did not match the tested questionnaire's quartiles of physical activity (Heini et al. 1996; Sobngwi et al. 2001).

Wareham (2001) emphasized that to develop internationally standardized questionnaires, such as the International Physical Activity Questionnaire, in all countries efforts will have to be made to ensure that validation and reliability studies take place.


The World Health Organization (WHO) defines obesity as a condition in which excess body fat has accumulated to such an extent that health may be adversely affected. The degree of body weight is usually expressed as BMI; this is the ratio of weight in kilograms to the square of height in meters. The BMI is used to classify a person's body weight as underweight (BMI less than 18.5), normal weight (BMI 18.5–24.9), overweight (BMI 25–29.9), or obese (BMI greater than 30) (WHO 2000).

In addition, it is customary to indicate the amount of abdominal fat mass. This can vary considerably among individuals who have the same BMI. Abdominal fat is reported by measuring the waist circumference or the waist-to-hip circumference ratio. The waist circumference is thought to provide a better correlate with abdominal fat mass than the waist-to-hip ratio. High abdominal fat mass is frequently referred to as central obesity. This form of obesity has been shown to have more morbidity than if the fat distribution is predominantly on the hips (WHO 2000).

Obesity greatly increases the risk for conditions such as type 2 diabetes, hypertension, dyslipidemia, gall bladder disease, sleep apnea, osteoarthritis, and lower back pain. It has also been shown to be associated with coronary artery disease and some cancers, and to reduce life expectancy. Central obesity has been shown to be associated with metabolic syndrome. The key features of this condition are raised blood pressure, raised insulin and triglyceride levels, reduced high-density lipoprotein (HDL)-cholesterol levels, and insulin resistance. The condition is strongly atherogenic and predisposes to an elevated risk of diabetes and cardiovascular disease (Fontaine et al. 2003; Peeters et al. 2003; Solomon and Manson 1997; WHO 2000).

In many Sub-Saharan Africa countries, an increased level of body fat is associated with beauty, prosperity, health, and prestige, despite its negative impact on health. Thinness, in contrast, is perceived to be a sign of ill health or poverty and is something to be feared and avoided, particularly in recent years, when it has been associated with AIDS (Treloar et al. 1999). In disadvantaged communities in South Africa, food is highly valued because food security has not always been ensured. Researchers found it to be socially unacceptable for an individual to refuse to eat food that was offered to them (Mvo, Dick, and Steyn 1999). Brown and Konner (1987) also reported that the majority of the less developed regions had, or still have, ideals of feminine beauty that include plumpness, which is consistent with the hypothesis that fat stores function as a cushion against food shortages during pregnancy and lactation. It is therefore unsurprising that studies have shown that black women in South Africa also do not perceive being overweight or obese as a health risk (Ndlovo and Roos 1999).

Urbanization, associated with changing dietary patterns and less physical activity and a rise in socioeconomic status, is occurring across Sub-Saharan Africa countries. All these factors lead to an increase in the prevalence of overweight and obese people in the region. This phenomena is illustrated in a study by Kruger and colleagues (2002) of the nutrition and physical activity patterns of a large sample of people from the North West Province of South Africa exposed to all levels of urbanization. The researchers found a significant association between household income and measures of obesity. They also saw a positive correlation between total energy intake, fat intake, and BMI. The physical activity index correlated negatively with BMI and waist circumference.

Cooper and colleagues (1997) also illustrated these trends when they compared the mean BMI of urban and rural West Africans with that of Jamaicans and blacks in the United States. A gradual increase in mean BMI was evident along the historical migration path of the West African diaspora that was attributed to a cross-cultural gradient of decreasing physical activity and Westernization of the diet.

Table 18.3 shows the prevalence of obesity from Sub-Saharan Africa reported in recent literature. South Africa has the highest prevalence of obesity in black men and women reported in Africa. Its prevalence among urban black women of 36 percent in South Africa already exceeds that of black women in the United States (Cooper et al. 1997; Puoane et al. 2002). The prevalence of obesity in South African and urban Tanzanian men was very similar, whereas the prevalence of obesity in South African women was almost double that of urban women in The Gambia and Tanzania.

Table 18.3. Anthropometric Indicators, by Country.

Table 18.3

Anthropometric Indicators, by Country.

An analysis of the mortality patterns associated with obesity in American people suggests that it has less of an impact on mortality and years of life lost in African Americans than in other Americans (Fontaine et al. 2003; Solomon and Manson 1997). Although no similar data are available on the association between obesity and mortality in Sub-Saharan Africa countries, it would be unwise to assume that obesity is benign for the people of this region. Reference has been made to the impact that obesity has on the emergence of hypertension, diabetes, and other chronic disease risk factors in Sub-Saharan Africa. Furthermore, high rates of LBW babies are common in the region, and this poses a risk to these babies in later life to develop obesity and other chronic disease risk factors.


High blood pressure is a major risk factor for heart attacks and strokes. It also contributes to renal disease and blindness. It is estimated that between 10 million and 20 million people in Sub-Saharan Africa have hypertension. It has been estimated that adequate hypertension treatment of these people could prevent about 250,000 deaths (Cappuccio et al. 2000). However, hypertension in Sub-Saharan Africa is universally under diagnosed or inadequately treated, or both, with the result that extensive end-organ damage and premature death are often seen. Furthermore, hypertension frequently co-exists with other NCD risk factors, such as diabetes. Seedat (1999) summarized the pathophysiology of hypertension and response to treatment as follows:

Black hypertensive patients in Sub-Saharan Africa are prone to cerebral hemorrhage, malignant hypertension, kidney disease leading to uremia and congestive heart failure, whereas coronary heart disease is relatively uncommon. Responses to antihypertensive medication drugs like the beta-blockers and the angiotension-converting enzymes (ACE) inhibitors are poor unless these agents are combined with a thiazide diuretic. Black patients respond best to diuretics, vasodilators or calcium channel blockers.

Kaufman and colleagues (1996) reported that the risk of death increased by 60 percent with an increase of 20 mmHg in diastolic blood pressure in rural Nigeria. They estimated that the population-attributable risk or the reduction in mortality that would have been observed if hypertension were not present was 7 percent, showing the impact of hypertension on all-cause mortality in rural Nigeria. Malignant hypertension also occurs more frequently in black people of Sub-Saharan Africa than in other ethnic groups. Milne and colleagues (1989) showed this in black patients hospitalized for hypertension. This condition is frequently related to severe renal disease and hypertensive encephalopathy. Data from the South African Dialyses and Transplantation Registry have shown that hypertension was responsible for 35 percent of end-stage renal failure in blacks and that malignant hypertension was diagnosed in 57 percent of the black patients with essential hypertension (Veriava et al. 1990). Untreated malignant hypertension has been shown to have a five-year survival as low as 1 percent.

Earlier surveys showed that the lowest prevalence of hypertension occurred in the poorest Sub-Saharan Africa countries, and as affluence increased, the prevalence increased. The surveys also revealed that hypertension was more common in urban than in rural settings in the region (Nissinen et al. 1988). The elegant Kenyan Luo migration study of Poulter and colleagues (1990) was the first to show that migration of people living in traditional rural villages on the northern shores of Lake Victoria to the urban settings of Nairobi was associated with an increase in blood pressure. This suggests a marked change in the diet of the new arrivals in Nairobi to a higher salt and calorie intake along with a reduced potassium intake due to consuming less fruit and vegetables. Studies carried out in Nigeria that compared urban and rural people's sodium and potassium excretions observed similar findings (Kaufman et al. 1999). Higher pulse rates in the Nairobi participants suggest that mechanisms related to increased autonomic nervous system activity could contribute to the higher levels of blood pressure observed (Poulter et al. 1985, 1990). Urban Nigerians reported higher stress levels and lower social integration scores than their rural counterparts. These indicators of increased stress in the urban setting were associated with higher blood pressures (Kaufman et al. 1999).

Socioeconomic status and urbanization are good predictors of hypertension. Zimbabwean women doing traditional work-related activities on rural communal land had lower blood pressures than did those women who were working for a wage on large-scale, commercial agricultural farms. The latter group, in turn, had lower blood pressures than women who earned a living in more industrial mining areas (Hunter et al. 2000). Similarly, researchers (Steyn, Fourie et al. 1996) found in the black community of Cape Town, South Africa, that the duration of urbanization independently predicted the presence of hypertension.

Table 18.4 shows the prevalence rate in some Sub-Saharan Africa countries from studies published since 1997. The studies reveal that although some countries still maintain large differences between urban and rural prevalence, differences are no longer apparent in many countries. The prevalence rates in the rural areas have increased to levels similar to those found only in the cities in the past. As an example, in the early 1990s Mollentze and colleagues (1995) showed that the rural community of QwaQwa in the Free State, South Africa, had rates of hypertension similar to those in the periurban community of Mangaung in the same province. The previously observed differences in hypertension prevalence between poorer and more affluent countries have also diminished.

Table 18.4. Large Prevalence Studies on Hypertension since 1997, by Country.

Table 18.4

Large Prevalence Studies on Hypertension since 1997, by Country.

Some dietary factors are related to hypertension, including increased salt (sodium) intake and a decrease in fruit and vegetables (potassium); a higher intake of alcohol products, particularly by men, also plays a role. The association between hypertension and obesity has been well documented in many countries in Sub-Saharan Africa. In Zimbabwe, Mufunda and colleagues (2000) found this strong association, as did Rotimi and colleagues (1995) in populations of West African descent. Despite this clear association it has been suggested that the noxious effect of obesity in black people is less than in people of other ethnic groups. Most of the supporting evidence for this viewpoint is based on studies carried out with African Americans in the United States. A small study in South Africa suggested similar findings (Walker et al. 1990). The influence of alcohol consumption, particularly heavy drinking, on increasing blood pressure levels has also been described in Nigeria (Bunker et al. 1992; Ekpo et al. 1992). The data on the association between high salt (sodium chloride) intake and hypertension in black people from Africa has been summarized by Seedat (1996) and suggests that black people have a transport mechanism of high sodium retention and a low rennin activity. Mtabaji and colleagues (1992) found salt sensitivity, measured by the blood pressure response on salt loading, in 46.2 percent of study subjects in Tanzania. A high intake of sodium is common in Sub-Saharan Africa, as it is used to preserve food or to make food tastier. For example, Cappuccio and colleagues (2000) described the diet in Ghana as consisting mostly of unprocessed food and highly salted fish and meat. Substantial amounts of salt are added to food while cooking, and monosodium glutamate–based flavoring cubes or salts are widely used to give food taste. In addition to a high salt intake, people in Sub-Saharan Africa frequently eat little fruit and vegetables, resulting in low potassium intakes.

Few intervention studies have been conducted in Sub-Saharan Africa to show that a reduction in salt and an increase in potassium improve the blood pressure in its populations. A study done in Tanzania showed that a low-sodium diet leading to a low urinary excretion level of 52 millimoles per day reduced blood pressure in normotensive people significantly within four to five days (Mtabaji, Nara, and Yamori 1990). A study in Kenya reported that supplementation with potassium in newly diagnosed patients with hypertension reduced the blood pressure to a level similar to that found in patients treated with a diuretic (Obel and Koech 1991).

These data clearly suggest that many nutritional interventions are required to decrease the prevalence of hypertension. These interventions include regulation of the amount of salt used by the food industry in Sub-Saharan Africa, the promotion of increased potassium consumption in the form of fruit and vegetables, and the limitation of alcohol use.

Despite the many environmental factors related to hypertension, many studies in Sub-Saharan Africa suggest a possible genetic contribution to the origins of hypertension in black people. Van der Sande and colleagues (2001) in The Gambia and Steyn and colleagues (unpublished data) in South Africa have found that high blood pressure is associated with a strong family history of either hypertension or stroke. This could provide a cost-effective opportunity to identify people who need more detailed screening for hypertension. Rotimi and colleagues (1999) used computer models and regression analyses to estimate the degree of heritability of systolic and diastolic blood pressure in Nigerian families. The heritability estimate was 45 percent and 43 percent for systolic and diastolic blood pressure, respectively. This emphasizes interaction between environmental influences and genetic factors in the etiology of hypertension.

In populations of African ancestry, data from small case-control studies and a large case-control study conducted in South Africa with more than 700 cases phenotyped using 24-hour ambulatory blood pressure monitoring and 700 controls (G. R. Norton et al., personal communications) suggest that the angiotensin-converting enzyme (ACE) gene variant contributes little to hypertension. Nevertheless, gender-specific effects need to be excluded. In addition, angiotensinogen (AGT) gene variants that have been associated with hypertension in Caucasian groups are not implicated in subjects of African ancestry (Tiago et al. 2002). However, an alternative functional promoter region variant of the AGT gene (−217G→A) has recently been shown to be strongly associated with hypertension in a small African American case-control study (Jain et al. 2002), data that has now been confirmed in a large case-control study conducted in black South Africans (G. R. Norton et al., personal communication). The role of the −217G→A AGT gene variant in contributing to the variance of blood pressure within families is now being assessed in a South African study. Furthermore, an additional functional AGT gene promoter region variant (−20A→C; Zhao et al. 1999) has been shown to modify the impact of body size on blood pressure (Tiago et al. 2002), and the −217G→A variant's effect on the risk for hypertension (G. R. Norton et al., personal communications) in subjects of African ancestry, thus suggesting complex genotype-genotype and genotype-phenotype interactions of the AGT gene in people of African origins.

Other candidate gene variants implicated in blood pressure control or hypertension in those of European or African ancestry, including functional or potentially functional variants found within the guanosine triphosphate protein β3 subunit gene (Siffert et al. 1998), the sodium epithelial channel gene (Baker et al. 1998), the α-adducin gene (Cusi et al. 1997), and the β2 receptor gene (Svetkey et al. 1996), have been shown not to be associated with hypertension in all studies conducted in groups of African ancestry (Candy et al. 2000; Larson, Hutchinson, and Boerwinkle 2000; Nkeh et al. 2003), or have been shown to occur with too low a frequency to contribute substantially to population-attributable risk (Barlassina et al. 2000). Family-based linkage studies assessing blood pressure as a continuous variable and using 24-hour ambulatory blood pressure monitoring techniques are under way in South Africa to further evaluate the role for these variants as determinants of blood pressure in groups of African ancestry.

Effective management of hypertension usually requires treatments with more than one drug. In Ghana, Hesse and Nuama (1997) found that only 18 percent of a group of patients with hypertension had one drug prescribed, whereas 60 percent had two drugs and 22 percent had three or more drugs prescribed. The use of two or more drugs will inevitably result in a high cost for antihypertensive medication, especially when newer medications are used. However, there are cheaper, older, and effective medications available in resource-scarce settings in Sub-Saharan Africa. Hesse and Nuama (1997) also reported that between 1973 and 1993 a diuretic was the type of drug prescribed for initial treatment of patients with hypertension; diuretics were used in 90 percent of cases, including reserpine in 46 percent, methyldopa in 31 percent, and propranolol in 30 percent. With the exception of methyldopa all these medications are inexpensive and suited to resource-scarce settings.

The benefits of treating hypertension have been convincingly shown in many parts of the world, but relatively little data are available from Sub-Saharan Africa. One example is a study by Salako and colleagues (1999), who showed that when patients with hypertension are given effective treatment, there is a reduction in the excretion of urinary albumin, suggesting improved renal function in patients who previously had early renal impairment.

After reviewing the available data, Cooper and colleagues (1998) suggested: "Hypertension is fully treatable, but social conditions in Africa make the implementation of blood pressure control programs difficult. Lack of a clear strategy based on evidence has undermined these efforts." They also estimated that effective hypertension treatment would lead to a reduction in population-attributable risk of 2 percent in Africa compared with 0.15 percent in the United States. "Number needed to treat" analyses showed that the cost of drugs to prevent one death is US$1,800 in Africa, if the cheaper drugs are used, whereas it is US$14,000 to US$1 million in the United States, depending on which drugs are used. Cooper and colleagues (1998) concluded that the treatment of hypertension should be a health priority in Sub-Saharan Africa.


Dyslipidemia is defined as a clinically significant alteration of the naturally occurring blood lipids and lipoproteins predisposing to cardiovascular diseases and other chronic diseases (Berger and Marais 2000). The two commonly measured blood lipids are cholesterol and triglycerides. These molecules are carried in a range of lipoprotein particles in the blood. The most important lipoprotein particles that predispose to atherosclerosis and thus cardiovascular diseases are the chylomicrons high in triglyceride and LDL particles, which carry mainly cholesterol. The LDL particle is the most atherogenic of all the lipoprotein particles. The HDL particle protects the arteries against atherosclerosis and, consequently, against cardiovascular diseases. HDL transports cholesterol away from the arteries to be excreted via the liver. The most recent international recommendations regarding lipid levels are that a total blood cholesterol level below 5.2 millimoles per liter is desirable; similarly, a level of LDL cholesterol below 2.6 millimoles per liter and a triglyceride level below 1.7 millimoles per liter are considered optimal. Persons with blood lipids below these levels do not carry a risk of developing atherosclerosis. An HDL cholesterol level below 1 millimole per liter also predisposes to atherosclerosis development, whereas a level above 1.6 millimoles per liter provides protection. The ratio of HDL cholesterol to the total cholesterol level, expressed as a percentage, is frequently reported. A level of more than 20 percent for men and 25 percent for women is considered to provide protection against developing atherosclerosis (Adult Treatment Panel III 2001).

A particularly atherosclerotic combination of lipid and other risk factors is referred to as the metabolic syndrome and leads to premature coronary heart disease. This syndrome consists of high levels of blood triglyceride, low levels of HDL cholesterol, and small dense LDL particles. It is also associated with type 2 diabetes, hypertension, abdominal obesity, insulin resistance, and physical inactivity. Van der Sande and colleagues (2000) found significant numbers of urban black people in Banju, the capital of The Gambia, with the coexistence of these conditions, suggesting that the metabolic syndrome is common in this city.

Since the level of ischemic heart disease reported in people from Africa is low, few hypertension and diabetes surveys in the region include blood lipid measurements. The available studies suggest that most people of African descent have far lower blood lipid levels than found in people of European or Indian descent in the region. These differences among the groups are present from a young age. In Johannesburg and Soweto, Steyn and colleagues (2000) found that the mean total cholesterol level in African and coloured five-year-old children was 3.9 millimoles per liter compared with 4.1 millimoles per liter for Indian and 4.4 millimoles per liter for white children. The corresponding ratios of HDL cholesterol to total cholesterol were 30.6 percent, 28.9 percent, 27 percent, and 25.8 percent, respectively. These findings in children at the age of five years correspond to the blood lipid pattern found in people of African descent in most studies carried out across Africa. These group differences in lipid profiles tend to continue into adolescence and adulthood. The lower total cholesterol and higher HDL cholesterol levels of persons of African descent indicate a protective pattern against developing atherosclerosis and, consequently, against ischemic heart disease (Steyn et al. 2000). Seftel and colleagues (1993) compared the lipid levels of male students between the ages of 15 and 20 years from different ethnic groups in South African urban and rural settings. The mean total cholesterol level was 3.2 millimoles per liter for the rural and 3.7 millimoles per liter for the urban students, differences that were statistically significant. The rural black males age 15 to 20 had the lowest total cholesterol level of all the groups studied. Only 1 percent of the rural and 2 percent of the urban black males had total cholesterol levels above 5.2 millimoles per liter.

In 1980 Knuiman, Hermus, and Hautvast (1980) reported even lower total cholesterol levels in rural and urban boys age seven to eight years in Côte d'Ivoire, Ghana, and Nigeria. The mean total cholesterol levels in these boys ranged from 2.6 millimoles per liter in rural Nigeria to 3.5 millimoles per liter in urban Ghana, and their ratio of HDL cholesterol to total cholesterol was high, varying from 30 to 36 percent. Walker and Walker (1978) also reported high levels of HDL cholesterol in African children and adults in a population free of coronary heart diseases.

Seftel, Raal, and Joffe (1995) reviewed the early studies on total cholesterol levels in South African adult populations. They found that the mean total cholesterol in middle-aged black men was about 4 millimoles per liter compared with 5 millimoles per liter in coloured men and 6 millimoles per liter in white men. Since the mean total cholesterol concentrations of newborn black and white babies were almost the same, the differences in middle-aged men were likely to be environmental in origin (Seftel, Raal, and Joffe 1995).

The findings of some recent lipid studies in Sub-Saharan African countries are shown in table 18.5. A study of 8,581 rural Tanzanians, age 15 years and older, found significantly higher mean total serum cholesterol levels in women than in men (Swai et al. 1993). Only in the economically more advanced region, Kilimanjaro, did the total cholesterol levels increase with age as found in all Westernized people. The favorable lipid profile in most of Africa may be threatened by the march of time. Njelekela and colleagues (2001) surveyed people for chronic disease risk factors in three settings in Tanzania in 1987 and again in 1998. Their findings suggest that during the decade, a significant rise occurred in the mean levels and in the prevalence of many cardiovascular disease risk factors, including increases in total cholesterol levels and the prevalence of hypercholesterolemia.

Table 18.5. Mean Lipid Levels and Prevalence of Dyslipidemia in Black Subjects.

Table 18.5

Mean Lipid Levels and Prevalence of Dyslipidemia in Black Subjects.

Two other cross-sectional studies in Tanzania assessed the impact of nutritional factors on the lipid profiles of people living in different settings. One compared the impact of the low-salt fish and vegetable diet on the lipid profile of Tanzanians with that of the typical diets consumed by people in Brazil and Italy (Pavan et al. 1997). The Tanzanians' total blood cholesterol and their BMI were lower than that of the other two groups. Another study compared the lipid profiles of Tanzanian villagers who consumed a diet consisting predominantly of fish with those of villagers who were predominantly vegetarian (Pauletto et al. 1996). The total blood cholesterol levels were lower (3.5 millimoles per liter) in the fish-eating community than in the vegetarian community (4.1 millimoles per liter). Similarly, the blood triglyceride levels were 0.9 millimoles per liter and 1.3 millimoles per liter, and the lipoprotein little (a) levels were 201 milligrams per liter and 321 milligrams per liter in the fish-eating community and vegetarian community, respectively (Pauletto et al. 1996). This study suggests that fish-eating communities have a more protective lipid profile than vegetarian ones.

Total cholesterol levels can be favorably influenced by improved dietary changes; however, increased physical activity patterns also improved the lipid profile. Researchers in Nigeria found that patients with hypertension, exercising three times a week for 30 minutes per session over a 16-week period, decreased their total cholesterol and LDL-cholesterol levels slightly and increased their HDL-cholesterol levels (Iyawe, Ighoroje, and Iyawe 1996).

Although high total blood cholesterol levels are uncommon in Sub-Saharan Africa countries, there are some exceptions. One example is provided by the descendents of the colonists from the Netherlands who came to the southern tip of Africa in the seventeenth century and belong to the Afrikaans-speaking white community in South Africa. The phenomenon referred to by geneticists as the "founder effect" is reflected in the high concentration of familial hypercholesterolemia in this group. A small group of farmers from the Cape province trekked north into the interior regions of what later became South Africa, and tended to intermarry. The background prevalence of heterozygous familial hypercholesterolemia across the globe is 1 to 500. However, the overall prevalence of familial hypercholesterolemia in rural, white, Afrikaans-speaking people in South Africa was estimated to be 1 to 72 (Steyn, Goldberg et al. 1996).

The treatment of high total blood cholesterol levels with medication is most cost-effective in people who have the highest risk of ischemic heart disease. These are people who have had a previous heart attack or stroke or who suffer from familial hypercholesterolemia and those with a typical Westernized lifestyle and who have more than one chronic disease risk factor. Although limited data are available on the treatment status of high blood cholesterol in Sub-Saharan Africa, a survey of about 13,000 patients of general practitioners in private practice in South Africa revealed that high blood cholesterol is poorly treated in those who could benefit the most. These were 18.7 percent of men and 10.4 percent of women who had ischemic heart disease in the past and whose total blood cholesterol levels were found to be 5.9 millimoles per liter and 6.0 millimoles per liter, respectively. These patients need to lower their total blood cholesterol levels significantly for protection against a recurrence of heart disease. This is an achievable objective with the use of highly effective newer cholesterol-lowering agents (Steyn et al. 1998).

HHealth Services' Requirements for the Management of NCD Risk Factors

Chronic disease rates are already higher than expected in Sub-Saharan Africa countries. Consequently, these patients are making significant demands on the health services. Appropriate planning to manage chronic diseases and their risk factors is of paramount importance in the region (Unwin et al. 2001). Most of the risk factors emerge during middle age as a result of an unhealthy lifestyle that has been followed for several decades. Many patients have several risk factors. In Nigeria it was found that patients may have as many as five chronic disease risk factors, as shown in table 18.6 (Ezenwaka et al. 1997). The risk factors have a synergistic effect on the total chronic disease risk. Health services planned for prevention and care must therefore take cognizance of the burden of multiple chronic disease risk factors in the same patient.

Table 18.6. The Clustering of NCD Risk Factors in Nigerian Subjects (percent).

Table 18.6

The Clustering of NCD Risk Factors in Nigerian Subjects (percent).

Data collected in large cohort studies conducted in the United States and the United Kingdom were used to assess the relationship between risk factors and cardiovascular disease (CVD) events. The studies used were the Framingham, Massachusetts, cohort data and United Kingdom cohort data (ATP III 2001; Grundy et al. 1999; Joint Task Force, 1998). Formulas were calculated that could be used to estimate a patient's chronic disease risk. These formulas usually express the patient's risk of suffering from a CVD event in the next 10 years or longer period. Health services are thus able to identify those patients who are at the highest risk of developing CVD and would benefit the most by using appropriate medication. Gaziano, Steyn, and Opie (2001) have shown that such an approach is more cost-effective than that of using single cut-off points for single CVD risk factors. Therefore, the total CVD risk-assessment approach clearly should be the one employed in settings with scarce resources, as is the case in Sub-Saharan Africa countries.

The model of health service provision prevailing across most of Sub-Saharan Africa is one that focuses on acute illnesses, the immediate needs of patients, and episodic interaction between the patient and the health services. This model does not provide adequate care for patients with chronic diseases. Consequently, millions of patients with chronic diseases in the region are undiagnosed or receiving inadequate treatment. The WHO conducted a two-year review of health care models and best practices from around the world. The findings, published in 2002, provided a comprehensive conceptual framework for the prevention and management of chronic conditions in poorly resourced settings (WHO 2002).

The WHO report focuses on the need to move away from the acute model of care to efficiently coordinated and patient-centered care. Such a move should facilitate an ongoing relationship between provider and patient and help patients to make full use of their own and their community's resources (Holman and Lorig 2000; Wagner 2000). This approach suggests that the focus should be on the patients in their own social settings and context and not only on the disease of the patient. This is of particular significance in Sub-Saharan Africa countries, where the patients' cultural beliefs and practices should be understood when prevention and management of chronic conditions are introduced. The partnership between the patient and the health care provider is not just a resource for understanding ill health, it is the basis for the prevention and management of chronic diseases and their risk factors (Swartz and Dick 2002).

Policy Initiatives to Promote a Healthy Lifestyle

The need for preventive action to reduce or prevent the adoption of a less healthy lifestyle by people in Sub-Saharan Africa has never been greater. Many factors contribute to the lack of chronic disease preventive programs being adopted by governments (Yach 2002).

The global health community has taken some significant steps to support countries in Sub-Saharan Africa and elsewhere to promote a healthy lifestyle for the entire world. The WHO, a branch of the United Nations, spearheaded this initiative by negotiations to propose a framework convention on Tobacco Control between 1999 and 2003. The member states of the WHO (2003) unanimously endorsed the framework convention of Tobacco Control to the WHO's general assembly in June 2004 for endorsement. The treaty attacks tobacco use in many ways. It expects countries to provide treatment for people who smoke, to encourage cessation, and to prevent the onset of tobacco use in the young. It requires countries to protect the public from exposure to environmental tobacco smoke and expects them to ban advertising to the extent that their constitutions allow with respect to the protection of commercial free speech. Thirty percent of any tobacco product's packaging should contain health warnings of the danger of tobacco use. Misleading words such as"light" or "mild" should also be banned. It encourages countries to raise taxes to the point that will discourage smoking and to pass laws that hold tobacco companies accountable for medical and other costs incurred because of tobacco use (WHO 2003). With the exception of South Africa, very few Sub-Saharan Africa countries have adequate tobacco control legislation in place to effectively protect their populations against tobacco use. This treaty will encourage many countries in the region to initiate such a development.

In March 2003 the WHO and the Food and Agriculture Organization, another branch of the United Nations, issued a scientific report reviewing the data on diet, physical activity, and health. The WHO has embarked on an extensive process of consultations across the globe, including Sub-Saharan Africa countries, to ensure that a global strategy provides realistic guidelines for all countries. The strategy will include a broad series of nutrition-related recommendations, including dietary advice along with proposals dealing with the labeling and advertising of food. Collaboration with the food industry is seen as pivotal to improving the quality of manufactured food and processed food.

All these initiatives will provide countries with information to identify and act appropriately to promote a healthy lifestyle. However, it is necessary to prioritize chronic disease prevention in view of all the other large health demands that face the ministries of health in Sub-Saharan Africa countries. Countries with multiple burdens of disease will have to develop priority-setting programs in order to plan how to use scarce resources most effectively. The failure of countries to adopt the necessary steps to promote a healthy lifestyle, however difficult such a decision might be early in the twenty-first century, will inevitably lead to increasing levels of obesity, hypertension, hyperlipidemia, and diabetes in the populations of Sub-Saharan Africa countries. This, in turn, will be the cause of an avoidable chronic disease epidemic within a few decades.


On reviewing the extent of chronic diseases in the low-income and middle-income countries, the Institute of Medicine of the United States National Academy of Sciences recommended that, in addition to the preventive actions required to reduce the risk factors, health services should diagnose and control hypertension and diabetes and should ensure access to low-cost drugs and the development of affordable clinical care algorithms. The report also emphasized the need to build capacity to conduct research and development activities and to develop institutional frameworks that would facilitate the development of chronic disease prevention activities and the transformation of the health care services to adequately cope with the enormous, mostly unacknowledged burden of chronic diseases in Sub-Saharan Africa (Howson et al. 1998).


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