The prescience of Shaper and Jones

Shaper and Jones are to be lauded for identifying the central role of cholesterol in determining variation in risk of coronary disease among different ethnic groups in Africa as early as 1959.1 Their publication followed closely the 1957 Seven Countries Study by Ancel Keys, which established unequivocally the pathophysiological role of dietary saturated fats acting through serum cholesterol concentrations in the causation of atherosclerotic vascular disease.2 The prescience of Shaper’s study of coronary artery disease is thrown into sharp relief because it challenged the prevailing assumption then that variation in risk of disease in Africans compared with Caucasians was genetic in origin; Africans were considered to be almost ethnically immune to the development of coronary artery disease.3,4 In fact, Shaper and Jones avoided the ‘racial profiling’ that was prevalent at the time by focusing in their study on measuring key components of environmental exposure, i.e. dietary composition. They identified the contribution of two of the main components of the diet–heart hypothesis to risk of coronary disease in Ugandans of African origin and those from the Indian subcontinent: (i) the intake of total fats, and proportion of animal (saturated) and plant (unsaturated) fats in the diet; and (ii) intake of vegetables and unrefined staple foods (i.e. vegetables, pulses and ground provisions—such as yams). They also hinted at the conditioning effect on risk of other lifestyle attributes, such as physical activity, but omitted mention of tobacco use. Since then, a large and robust literature has confirmed that the relationships between common cardiovascular disease risk factors and acute myocardial infarction are similar throughout the world.5

The surprising omission from their report was an index of obesity; there is no information on weight or height or any measure of body size or composition. The association between overweight and coronary disease was well established by then.6 Perhaps, the focus on cholesterol as a major risk factor modifiable by simple dietary changes was the sole aim of the communication. Perhaps, also, they were correct to ignore easily measured indices of obesity such as BMI because of the recognized variation in proportion of fat and lean mass at any BMI and the consequent variation in risk that is mechanistically associated with adiposity. Certainly, relative weight captured as the BMI and cardiovascular risk are not absolutely correlated, as has been demonstrated in the Seychelles and South Africa.7,8 Although obesity has increased in the Seychelles and South Africa, mortality from coronary artery disease appears to be falling in both African countries.9–11 A current enumeration of the main risk factors for coronary disease would not differ substantially therefore from Shaper’s early framework; thus, almost nothing significant has been observed about risk of coronary artery disease that is not in the article, except for cigarette smoking and the variation in underlying susceptibility to risk exposures that is conditioned by early life development.12 The initial recognition by Barker and the subsequent elaboration of understanding of this variation in underlying susceptibility to the pathogenetic force of risk factors arising from developmental modulation of individual form and function is a major advance in the understanding of disease risk.13 Ironically, it comes perilously close to rehearsing old fallacies of the genetic basis of observed ethnic differences in disease profile because of the divergence of ethnic biological phenotypes, driven by generations of environmentally entrained epigenetic control of development early in life.14

Are we any further along on prevention than we were then?

The study was conducted >50 years ago when coronary artery disease was almost non-existent in Black people of Uganda and the rest of the continent.3,15 According to the latest WHO data published in April 2011, coronary artery disease caused 13 569 or 3.65% of total deaths in Uganda, with an age-adjusted death rate of 130.92 per 100 000 of population, which ranks number 69 in the world.16 Although an upward trend in the incidence of coronary artery disease among Africans has been reported,17–19 the rates of coronary heart disease as a cause of heart failure remain relatively low in Southern, Eastern, Central and Western Africa compared with other regions of the world.20–22 Furthermore, there is a glimmer of hope that in middle-income African countries that have implemented preventive measures, such as stringent anti-smoking legislation,23 the mortality rate from coronary artery disease is falling,10,24 highlighting the fact that coronary artery disease is preventable through attention to the environmental exposures that were identified by Shaper and Jones.

What about the future?

Africa has the historic opportunity for avoiding the epidemic of coronary artery disease before it takes root on the continent by adopting public health best practices.19 African governments need to develop intersectoral policies and targets for prevention of coronary artery disease, such as those of South Africa,25 which are aligned with the United Nations high-level meeting on non-communicable diseases.26 The critical issues that need to be resolved to ensure that recent political commitments are translated into practical action include the following: (i) adopting a life course approach to the prevention of cardiovascular and other non-communicable diseases (NCDs); (ii) measuring the burden of NCDs at a population level to inform government and donor funding commitments and priorities for intervention; (iii) finding the right balance between the relative importance of treatment and prevention to ensure that responses cover those at risk, and those who are already sick; (iv) defining the appropriate health systems response to address the needs of patients with diseases characterized by long duration and often slow progression; (v) research needs, in particular translational research in the delivery of care; and (vi) sustained funding to support the NCD response of developing countries.27

These responses need to take cognizance of the heavy burden of infectious diseases as the leading causes of mortality in sub-Saharan Africa, and address the interaction between infectious diseases (such as HIV/AIDS and tuberculosis) and chronic diseases (such as chronic obstructive lung disease and diabetes).28,29 In addition to the heavy burden of infectious diseases, and the emergence of chronic non-communicable disease, many communities in sub-Saharan Africa also suffer from unacceptably high mortality from preventable perinatal and maternal conditions, as well as injury and violence. The quadruple burden of communicable, non-communicable, perinatal and violent deaths is producing a complex health transition, which demands an extraordinary response.9,30 For example, the persistent burden of malnutrition in young children yet growing overweight and obesity among adolescents generates the ‘perfect mix’ of factors for later cardiometabolic disease.31,32 At the other extreme, HIV prevalence among older persons is far higher than previously recognized, underlining the importance of chronic comorbidities and posing unexpected, growing challenges to primary care practice.33 The importance therefore, of understanding health and illness along the life course, and where to intervene, is paramount in developing the agenda for prevention of cardiovascular and other diseases in Africans beyond the era of Millennium Development Goals.

Conflict of interest: None declared.

References

1
Shaper
AG
Jones
KW
Serum-cholesterol, diet, and coronary heart-disease in Africans and Asians in Uganda
Lancet
 , 
1959
, vol. 
2
 (pg. 
534
-
37
Reprinted in Int J Epidemiol 2012;41:1221–25
2
Keys
A
Anderson
JT
Grande
F
Prediction of serum-cholesterol responses of man to changes in fats in the diet
Lancet
 , 
1957
, vol. 
273
 (pg. 
959
-
66
)
3
Brock
JF
Gordon
H
Ischaemic heart disease in African populations
Postgrad Med J
 , 
1959
, vol. 
35
 (pg. 
223
-
32
)
4
Vermaak
WJH
Ubbink
JB
Delport
R
Becker
PJ
Bissbort
SH
Ungerer
JPJ
Ethnic immunity to coronary heart disease?
Atherosclerosis
 , 
1991
, vol. 
89
 (pg. 
155
-
62
)
5
Steyn
K
Sliwa
K
Hawken
S
, et al.  . 
Risk factors associated with myocardial infarction in Africa—The INTERHEART Africa Study
Circulation
 , 
2005
, vol. 
112
 (pg. 
3554
-
61
)
6
Keys
A
Obesity and degenerative heart disease
Am J Public Health
 , 
1954
, vol. 
44
 (pg. 
864
-
71
)
7
Bovet
P
Romain
S
Shamlaye
C
, et al.  . 
Divergent fifteen-year trends in traditional and cardiometabolic risk factors of cardiovascular diseases in the Seychelles
Cardiovasc Diabetol
 , 
2009
, vol. 
8
 pg. 
34
 
8
Puoane
T
Steyn
K
Bradshaw
D
, et al.  . 
Obesity in South Africa: The South African demographic and health survey
Obesity Research
 , 
2002
, vol. 
10
 (pg. 
1038
-
48
)
9
Mayosi
BM
Flisher
AJ
Lalloo
UG
Sitas
F
Tollman
SM
Bradshaw
D
The burden of non-communicable diseases in South Africa
Lancet
 , 
2009
, vol. 
374
 (pg. 
934
-
47
)
10
Stringhini
S
Sinon
F
Didon
J
Gedeon
J
Paccaud
F
Bovet
P
Declining stroke and myocardial infarction mortality between 1989 and 2010 in a country of the African region
Stroke
 , 
2012
, vol. 
43
 (pg. 
2283
-
88
)
11
Finucane
MM
Stevens
GA
Cowan
MJ
, et al.  . 
National, regional, and global trends in body-mass index since 1980: systematic analysis of health examination surveys and epidemiological studies with 960 country-years and 9·1 million participants
Lancet
 , 
2011
, vol. 
377
 (pg. 
557
-
67
)
12
Gluckman
PD
Hanson
M
Zimmet
P
Forrester
T
Losing the war against obesity: the need for a developmental perspective
Sci Transl Med
 , 
2011
, vol. 
3
 pg. 
93cm19
 
13
Barker
DJP
Commentary: birthweight and coronary heart disease in a historical context
Int J Epidemiol
 , 
2006
, vol. 
35
 (pg. 
886
-
87
)
14
Gluckman
PD
Bergstrom
CT
Evolutionary biology within medicine: a perspective of growing value
BMJ
 , 
2011
, vol. 
343
 pg. 
d7671
 
15
D’Arbela
PG
Kanyerezi
RB
Tulloch
JA
A study of heart disease in the Mulago hospital, Kampala, Uganda
Trans R Soc Trop Med Hyg
 , 
1966
, vol. 
60
 (pg. 
782
-
90
)
16
Uganda: coronary heart disease
World Health Rankings – Live Longer, Live Better. 2011
 
17
Akinboboye
O
Idris
O
Akinkugbe
O
Trends in coronary artery disease and associated risk factors in sub-Saharan Africans
J Hum Hypertens
 , 
2003
, vol. 
17
 (pg. 
381
-
87
)
18
Mensah
GA
Ischaemic heart disease in Africa
Heart
 , 
2008
, vol. 
94
 (pg. 
836
-
43
)
19
Opie
LH
Mayosi
BM
Cardiovascular Disease in Sub-Saharan Africa
Circulation
 , 
2005
, vol. 
112
 (pg. 
3536
-
40
)
20
Commerford
P
Mayosi
B
An appropriate research agenda for heart disease in Africa
Lancet
 , 
2006
, vol. 
367
 (pg. 
1884
-
86
)
21
Commerford
P
Ntsekhe
M
Ischaemic heart disease in Africa. How common is it? Will it become more common?
Heart
 , 
2008
, vol. 
94
 (pg. 
824
-
25
)
22
Damasceno
A
Mayosi
BM
Sani
M
, et al.  . 
The etiology, treatment and outcome of acute heart failure in 1006 Africans from 9 countries: results of the sub-Saharan Africa survey of heart failure (THESUS-HF)
Arch Int Med
 , 
2012
 
doi:10.1001/archinternmed.2012.3310
23
Peer
N
Bradshaw
D
Laubscher
R
Steyn
K
Trends in adult tobacco use from two South African demographic and health surveys conducted in 1998 and 2003
S Afr Med J
 , 
2009
, vol. 
99
 (pg. 
744
-
49
)
24
Mayosi
BM
Flisher
AJ
Lalloo
UG
Sitas
F
Tollman
SM
Bradshaw
D
The burden of non-communicable diseases in South Africa
Lancet
 , 
2009
, vol. 
374
 (pg. 
934
-
47
)
25
Department of Health
South African Declaration on the Prevention and Control of Non-Communicable Diseases
 , 
2011
Pretoria
26
Beaglehole
R
Bonita
R
Alleyne
G
, et al.  . 
UN high-level meeting on non-communicable diseases: addressing four questions
Lancet
 , 
2011
, vol. 
378
 (pg. 
449
-
55
)
27
Maher
D
Ford
N
Unwin
N
Priorities for developing countries in the global response to non-communicable diseases
Global Health
 , 
2012
, vol. 
8
 pg. 
14
 
28
Creswell
J
Raviglione
M
Ottmani
S
, et al.  . 
Tuberculosis and noncommunicable diseases: neglected links and missed opportunities
Eur Respir J
 , 
2011
, vol. 
37
 (pg. 
1269
-
82
)
29
Levitt
NS
Steyn
K
Dave
J
Bradshaw
D
Chronic noncommunicable diseases and HIV-AIDS on a collision course: relevance for health care delivery, particularly in low-resource settings—insights from South Africa
Am J Clin Nutr
 , 
2011
, vol. 
94
 (pg. 
1690S
-
96S
)
30
Tollman
SM
Kahn
K
Sartorius
B
Collinson
MA
Clark
SJ
Garenne
ML
Implications of mortality transition for primary health care in rural South Africa: a population-based surveillance study
Lancet
 , 
2008
, vol. 
372
 (pg. 
893
-
901
)
31
Kimani-Murage
E
Norris
S
Pettifor
J
, et al.  . 
Nutritional status and HIV in rural South African children
BMC Pediatrics
 , 
2011
, vol. 
11
 pg. 
23
 
32
Kimani-Murage
EW
Kahn
K
Pettifor
JM
Tollman
SM
Klipstein-Grobusch
K
Norris
SA
Predictors of adolescent weight status and central obesity in rural South Africa
Public Health Nutr
 , 
2011
, vol. 
14
 (pg. 
1114
-
22
)
33
Mills
EJ
Bärnighausen
T
Negin
J
HIV and Aging—Preparing for the challenges ahead
N Engl J Med
 , 
2012
, vol. 
366
 (pg. 
1270
-
73
)