We found the review by de Valk and Marx1 on iron, atherosclerosis, and ischemic heart disease extremely interesting. The primary reason for our interest concerns the situation of dietary iron overload in many populations in southern Africa, a phenomenon that is associated, inter alia, with a low frequency of severe atherosclerosis and/or a low occurrence of ischemic heart disease (IHD).
As described in a recently published review,2 iron overload (siderosis) in Africans was very common in the 1960s and 1970s.3 While its prevalence has diminished because of changes in dietary and other practices, a study done in a rural village in 1990 revealed that two thirds of elderly men and a third of elderly women had serum ferritin levels of 200 µg/L or higher. As for atherosclerosis, past surveys revealed the prevalence of severe lesions of the aorta in this population to be low4; in large measure, this is still the case, judging from unpublished observations. Ischemic heart disease is still relatively rare; in Soweto (3 million inhabitants), which is adjacent to Johannesburg, the disease accounts for less than 0.5% of total deaths.5