Obesity in the era of poverty and HIV

2017-01-24 07:48

Picture: Mail and Guardian


South Africa is fast becoming popular to neighbouring countries especially those affected by political instability, or simply for better jobs or economic opportunities. We have one unique setup that sees a wide gap between the underprivileged and the well off, as such we find ourselves crippled by a wide spectra of diseases. The negative end of the malnutrition classification, a disease of poverty, still affects a large number of children and adults in impoverished and rural parts of our country. It is also not unique for these areas to experience high HIV infectivity rates.

A twist to the setup involves emerging diseases of lifestyle or non-communicable diseases. The other end of the malnutrition classification is being overweight. People generally think of malnutrition as kwashiorkor or marasmus, affecting children who are not receiving enough protein or energy filled foods, vitamins and minerals. Being overweight, obese or morbidly obese, that too is malnutrition.

How do we get overweight people in a community living below the poverty line? Could it be that these are previously disadvantaged people who are now in semi-urban areas? If we look at native Africans or black people, aren’t the “fat” ones tenderpreneurs, fertile women or big mamas? Surely being “big-boned” is much better than being skinny? After all, in a community that fears and holds a strong stigma against HIV positive people, being thin is not an option right? Let us unpack some of these issues and look at some researched facts.

Picture: The economist

Body Mass Index (BMI)

In the 1900’s, Adolphe Quetelet developed a formula that calculates the body mass index (BMI). This formula is still in use to determine if one’s weight is appropriate for their height. It is measured in kg/m2 and classifies individuals as: underweight (BMI <18.5), normal weight (BMI 18.5-24.9), overweight (BMI 25-29.9), obese (BMI 30-39.9) and morbidly obese (BMI > or = 40). To calculate your own BMI, simply take your weight in kilograms and divide it by your height in metres squared (or height multiplied by itself). This formula applies to both men and women. An 80kg man, who is 1.75 metres tall has a BMI of 26.12 [80/ (1.75 x 1.75)].

The formula is not 100% reliable, as it doesn’t really measure body fat. Some people with a lot of fat cells may have a normal BMI. Lean people with more muscle mass may score as overweight because muscle is denser than fat cells. It also takes one’s BMI a while to adjust despite changing one’s diet and lifestyle, which can be discouraging to people aiming to lose weight based on their dieticians’ or clinicians’ recommendation.

BMI is also not specific to fat cell types. It has been proven that abdominal fat is more concerning than hips or rear fat. The abdominal fat is measured as waist circumference. In men 102cm and 88cm in females are considered high risk. These are linked to an increased risk for diabetes (type 2), high lipid or fat in the blood (dyslipidaemia), hypertension and coronary vascular disease (heart attack). It is unfortunate to say that being raised to think “beer bellies” are cool was and is a lie.

Picture: Mosaic Science

Obesity in South Africa

In the Sub-Saharan Africa, our overweight and obesity prevalence is the highest. Our women with BMI >25 are at 56% and men at 29%. Out of a 100 women, 56 South African women are overweight. Black women are ranking higher than women of other races (58.5%). It is not a surprise that urban women are significantly more overweight than their rural peers. So, this means that our “fertile women” are affected and at a risk of getting lifestyle diseases. Heart attacks in black South Africans are still statistically lower compared to Caucasians. Children are affected by obesity as well, with a mixed picture. Rural kids grow up stunted (short for age) and are at a risk of being overweight later in life. Urban kids (ages 1 to 9) are increasingly becoming overweight, currently at 17.1%. Black kids of the 10-15 years age group sampled at a study in the North West were found to be slightly more overweight (17.4%) compared to kids of mixed origin (16.8%) but less compared to white (19%) and Indian kids (17.5%).

If obesity is seemingly such a big problem in our country, is our government doing anything about it? Actually, the department of health is at war against non-communicable disease. They have acknowledged the impact obesity has on the progression of non-communicable conditions. In the 2015-2020 strategy for the prevention and control of obesity in South Africa manual, Minister of Health Dr PA Motsoaledi states : “At the heart of this national strategy for the prevention and control of obesity is the realization that non-communicable diseases have placed a dire threat on the physical and mental health of the South African population. With obesity a major risk factor for the development of non-communicable diseases, global regional and national interventions need to be implemented in order to halt the growth of both epidemics”.

Picture: A comparative risk assessment for South African 2000

Globally, 5% of deaths are attributable to obesity. As it is, South Africa is struggling with other risk factors that cause early deaths and years of life lived with disability. These are called risk factors for disability adjusted life years (DALYS). The top ranking of these risk factors is unsafe sex, followed by interpersonal violence, alcohol harm, tobacco smoking and excess body weight. It is sad to see that our teenagers are exposed to these factors. A possible scenario in our modern day South Africa would be a 15 year old girl that falls pregnant after her first unprotected sexual encounter. Only to discover a few months down the line that she is also HIV infected. She is likely to leave school early, become a victim of domestic violence and interpersonal violence. Picture how she might cling on to alcohol, smoking and unhealthy eating habits to try and numb her pain. She might later become an overweight adult, if she doesn’t get full blown AIDS, with associated non-communicable diseases. This scenario highlights and emphasizes why it is important to not only focus on obesity, but other risk factors as well. A holistic approach if you will.

By the year 2020, our department of health hopes to have achieved the following targets, as part of the national non-communicable diseases strategic goals, to assist with obesity:

Increase physical activity by 10% (let’s hope members of parliament will lead by example)

Reduce consumption of alcohol by 20% (surely Sunday the 8th of January 2017 was a fluke)

Reduce the percentage of people who are overweight or obese by 10%.

Why you might ask? So we can have a healthy nation, of course.

Why am I overweight?


It is always easier to blame genes for our weight gain, than accept that we have a big role to play. We compare ourselves to people that apparently consume more food than we do. Interestingly enough, only 25% of the variation in percent body fat and total fat mass is a result of genetic factors. This leaves 75% to culture and lifestyle. Correct, our very own way of living has a bigger role to play in how much weight we gain. The complex interaction of genes and the environment is still unpredictable, especially in a South African setting.

Early life influences

Some research has been done looking at factors that affect a foetus (baby in the mother’s womb) and influence weight gain later in life. There are inconclusive studies, some however agreeing that babies born with a low birth weight are at a higher risk of obesity, insulin resistance and hypertension later in life.

Medical conditions and medication

Conditions like hypothyroidism (under active thyroid gland), Cushing’s syndrome and polycystic ovarian syndrome can cause significant weight gain. Certain prescription medication are also responsible for undesirable weight increase, some doing so by increasing appetite.

Dietary intake

It has always been understood that high calories lead to obesity. High fat diets are known to cause significant fat accumulation than high carbohydrate diets. Fatty foods are known for their good palatability (relating to taste), weak satiating effect (they don’t fill you up as well as carbohydrates) and high energy density. These factors may explain why high fat diets promote more fat accumulation. If food tastes good but doesn’t fill you up, you will continue eating. If food has more energy and you use less of that energy, the rest will be stored in fat cells. Some high fat diets are becoming popular but are not for discussion in this article .Urbanisation has affected us negatively, health wise, quicker than developed countries over the years during their industrialisation. An average urban South African family has a 10.9% decrease in carbohydrate intake and a 59.7% increase in a high fat diet. In the rural areas, only a small fat increase percentage of 8% was noted. A correlation was made between a high BMI and high fat diet intake, in a study done in North West province.

Some research suggests that high fat diet might be linked to high BMI, but also explores the possibility of slow resting and exercising metabolism of fat cells (oxidation) in African women. This was confirmed in African American women, where a study did indeed show lower levels of fat oxidation at rest and during exercise, compared to Caucasian women.

Physical activity

The protective effect of physical activity is important in preventing weight gain and lifestyle diseases. Exercise also helps with energy expenditure and metabolism, maintaining weight loss and increasing adherence to diet for weight loss. Inactivity is associated with obesity in South Africa in a study amongst black women. With school children, exercise is also shown to prevent obesity. It has been shown that children from lower socio-economic homes, who watch more T.V. and have fewer after-school sporting activities are generally more overweight.

 Socio-cultural factors

Men and women have inadequate perceptions of their body weights. From a group of men in a study, 29.2% were overweight. However, only 9.7% of them thought they were overweight. In the women’s group, of the 56.6% overweight women, only 22.1% thought there were overweight. White women perceived themselves (54%) more accurately, while only 16% of black women thought they were overweight. We are our own enemies after all; no one thinks they are overweight.


Women with a lower education level were found to have a poor perception of their weight, especially in a group of black women. This brings up the issue of how girls are usually raised in the rural areas, with talks of fertility and having the “motherly” look. Men sometimes express how they are generally attracted to thicker women. Men with more than 8 years schooling were in contrast found to have higher BMIs. What shows the community how happy and wealthy we are better than weight gain, right? Is this how “sugar daddies” and “blessers” are made? Apparently, the higher level “blessers” are big people, figuratively and literally.

Number of live children (parity)

In an American study, a 7% increase in the risk of obesity was seen in women after each child. And a 4% increase was noted in men, highlighting the importance of lifestyle changes in both sexes. If men who did not carry children also gained weight, surely it is not only hormones affecting women’s weight. In women, gaining weight during pregnancy could predict sustained weight retention a year after the woman has given birth. There was also a link in lifestyle changes in those group of women and they didn’t significantly attribute weight gain to any biological or metabolic factors. The known biological risks of weight gain after pregnancy are high BMI before pregnancy, young age at start of menstruation or menarche (age < 12 years), maternal age (24-30 years), time period from menarche to first birth (< 8 years) and high weight gain during pregnancy. A 25 year old, starting pregnancy with a BMI of 30, who had her first period at age 11 and gains a lot of weight during pregnancy is at a greater risk for significant weight gain after pregnancy.


A link between chronic stress, comfort eating and weigh gain was found in a study done in nurses. The stress of urbanisation was also a suspected cause for unhealthy eating behaviour and inactivity amongst black people that moved from rural areas. Who doesn’t like comfort food?

What are the medical problems associated with obesity?

Life style Diseases: Type 2 diabetes, high total cholesterol, low HDL cholesterol (the good fats), hypertension, metabolic syndrome (combination of the aforementioned), stroke and coronary artery/heart disease (heart attack).

Cancer: in males, rectum, colon and prostate are more common. In women, breast, uterus, cervix, endometrium and ovaries. Other cancers associated with obesity include oesophagus, liver, gall bladder, pancreas and kidney.

Psychological implications are not limited to unhappiness, body image issues and disordered eating. Obese people may not enjoy activities that others do, in fear of being humiliated. They may isolate themselves and feel guilty for how they are. Their quality of life is reduced and some may have physical and mental limitations in their day to day activities. Depression is quite common and suppressed anger is seen amongst those who don’t meet cultural ideals for their weight.

Osteoarthritis of the knees and ankles is easier to explain if one considers that the joints are carrying a load that exceeds their capacity. As some people harshly put it (referring to morbidly obese individuals), it’s like a truck running on bicycle tyres.

Breathing problems like sleep apnoea can be lead to unexplainable early morning headaches, mood disorders and poor quality of life with daytime sleepiness and fatigue.

Reproductive Health: Infertility, irregular periods and sexual dysfunction can negatively affect marriages.

There are many other complications.

How can I lose weight?

We are seeing so many weight loss adverts on a daily basis. If it were easy, we wouldn’t be having 13.1% deaths attributable to non-communicable diseases, compare to 13.8% deaths due to Aids complications. Our country has taken some steps in addressing these risk factors and disease burdens. An inter-sectoral collaboration extending beyond the department of health is being applied to tackle obesity-related issues. At a community level, an empathic multidisciplinary team can assist with individualizing each case, using a non-judgemental approach.

The most important step in managing being overweight, obesity or morbid obesity is accepting that you need help. Speak to your GP and dietician about your starting point.

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