**3. Methodology**

*Lifestyle and Epidemiology - The Double Burden of Poverty and Cardiovascular Diseases...*

of food insecurity is thus monotonous diets with consumption of more affordable energy-dense staples and foods that may have detrimental health outcomes such as obesity and its chronic disease comorbidities. [9] Food insecurity thus does not only cause under-nutrition, but also in over-nutrition such as obesity and its comorbidities, especially in low-income communities. [10] SA is a country in health transition and suffers from a quadruple burden of (a) poverty and nutrition-related chronic diseases of lifestyle [CDL], (b) communicable diseases, (c) peri-natal, maternal and injury-related disorders, [11] and (d) a nutrition transition. A recent study has found that this quadruple burden of disease is predominantly present in the black African population. [1] Urbanisation and westernisation of the Black African population of SA is marked not only by demographic transition, but also by increased animal protein, total dietary fat and added sugar intakes [11] and a health transition resulting in an increased prevalence of obesity [6] and CDL such as CVD. [11, 12]

**2. Double burden of poverty and cardiovascular disease among black** 

The South African population of approximately 59 million people consists of 81% black Africans. [13] In 2017, it was reported that 56% of the SA population lived in poverty [14] with 28% living in extreme poverty, thus not having enough money to purchase enough food to consume around 2,100 calories per day for a month (food poverty). The most vulnerable to food poverty are women, children (66.8%), those with low education (79.2%) and people from the black population

CVD incidence is increasing rapidly among all population groups in SA. [11] CDLs contribute 51% to the mortality rate, with CVD and diabetes accounting for 19% and 8% of the total deaths. Many people in SA have poor living conditions and limited resources to maintain health and well-being. [15] In spite of cultural background, people that has been subjected to urbanisation, has adopted a more Western lifestyle with lower dietary fibre and higher dietary fat and added sugar intakes, as well as lower physical activity levels. These dietary changes have led to higher prevalence of CDL, [17] specifically an increased risk and susceptibility of CVD among the black population, [18] and not only in adults, but also among children. [19] The face of CVD has thus changed in recent years. Initially it was a disease of the white population group, the affluent and older generations, but since the 2000s, it was also observed that the prevalence of CVD risk factors, such as dyslipidaemia and obesity, has increased among black Africans [20] as well as

The aim of this chapter was thus to investigate the prevalence of the various

cardiovascular risk factors, specifically those that are irreversible, among children (6–18 years old) in peri-urban Free State (FS), [25] rural Eastern Cape (EC), [24, 26–28] peri-urban [29] and urban [30–33] Gauteng; adults (19–59 years old) in urban Gauteng [30, 31, 34–37] and peri-urban FS; [38–40] and elderly (≥60 years) in urban Gauteng, [41–43] including both genders, living in poverty in SA. Gauteng was chosen as the authors both resided in Gauteng and it was the focus of the university for funding. No data had been available for the cardiovascular risk factors in the above-mentioned communities and a valuable research opportunity was created to address the paucity of information in these communities. For this reason, the FS and EC provinces were chosen because of funding opportunities and gap in the knowledge base on the areas included in

**south Africans**

group (64.2%). [15, 16]

children and adolescents. [21–24]

**46**

these studies.

A search of electronic databases focusing on poverty, food insecurity and cardiovascular risk factors was carried out between 2010 and 2020. Databases used included: MEDLINE (PubMed), Web of Science, ScienceDirect, Scopus, EBSCOHost, Springer Link, and Sabinet. The keywords used included: "poverty", "food security", "nutrition security", "food and nutrition security", "cardiovascular disease", "CVD", "cardiovascular risk", "CVR", "cholesterol", "triglycerides", "HDL", "LDL", "C-reactive protein", "CRP", "fibrinogen", "homocysteiene", "vitamin B6", "vitamin B9", "folate", "folic acid", "vitamin B12", "glucose", "insulin", "obesity", "overweight", "nutritional status", "hypertension", "high blood pressure", "dietary diversity", "dietary intake", "children", "adults", "elderly", "older people", "aged", "double burden", and "South Africa".

The data used for this chapter included all the databases and articles published for the various studies undertaken by the authors between 2000 and 2020 among black children in the EC, FS and Gauteng, [24–28, 30–32, 36] adults in Gauteng and the FS [25, 30, 35, 37, 40] and the elderly in Gauteng [37, 41, 43] in various urban, peri-urban and rural areas of SA. For the purpose of this book chapter, urban areas include cities and towns that are developed, thus having a density of human structures such as houses, commercial buildings, roads, and public transport. Periurban areas are underdeveloped areas on the outskirts of the towns and cities where people live, but no public transportation or commercial buildings are present. Rural areas refer to areas with low population density and large areas of undeveloped land where people mainly live far apart from their neighbours.

Comparative tables were drawn up using the published articles and, where data were not published, descriptive statistical analyses (frequencies) were calculated using IBM SPSS Statistics, version 26, from the study databases that had not been destroyed. The ethical and scientific procedures for the sampling strategy and data collection methods were the same for the published and unpublished data.

## **4. Poverty and food insecurity**

Poverty and food insecurity were observed in all seven study communities. A large majority of the adults (75.7%–78.0%) [35, 44] and child caregivers (53.0%–94.0%) [27, 29, 30, 44] were unemployed, had either no or only primary education (39.9%– 78.8%), [27, 29, 30, 34, 36, 43, 44] and lived in poverty (67.7–100%). [27, 29, 35, 36, 44] The poverty rates of all the communities were more than double the 25.2% national food poverty rate. [15] This may have been due to the high unemployment rate and low education levels found among the adults in all the communities. A chronic money shortage to buy food was also reported in large percentages of the study population.
