CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 9/10, October/November 2013
AFRICA
373
In low-income countries in SSA, children of overweight
mothers are often underweight,
82
which differs from the situation
in SA in which children of overweight mothers are more likely
to be overweight.
83
The notion that food insecurity is implicated
in adult obesity is paradoxical, but may be explained by the
consumption of energy-dense foods of low nutritional value.
Body image
Cross-sectional studies have revealed that, unlike the vast majority
of women who favour the lean, Westernised archetype, there is
a preference for a larger body size among black SA women.
32
This ideal stems from a cluster of culture-bound beliefs, which
promote lifestyle behaviours commonly associated with obesity.
International research has consistently shown that, after
controlling for age, education, socio-economic status and body
weight, men, irrespective of ethnicity, and black women display
the lowest degrees of body size dissatisfaction compared to other
ethnic groups.
84-87
Furthermore, results from the SADHS confirm
that black women were more likely to under-estimate their body
size compared to women of other ethnic groups.
12
In addition
to black SA families showing a greater tolerance for increased
body size,
33
strong mother–daughter resemblances have been
identified for numerous body image constructs, including body
size ideals and perceptions of body size dissatisfaction.
88
Socialisation moulds the body image of these women
throughout all life stages, and may explain why this ideal is
so well maintained from early childhood into adulthood. For
instance, young girls are encouraged to be plump, with weight
gain prior to marriage indicative of fertility and the ability to
bear children.
89
In addition, while men are socialised to do hard
labour, girls are expected to perform light labour, which may
provide limited motivation for a leaner body since activities of
this nature do not necessitate high levels of physical aptitude.
90
Similarly, low physical activity is due to the belief that
physical activity is associated with weight loss, as well as
sub-optimal environmental conditions such as a high crime rate
and overcrowding.
12,32
Notably, similar attitudes toward weight
control have been found among black women in rural areas,
where it was shown that most overweight and obese women did
not desire weight loss.
91
Ethnic body size preferences have been shown to govern how
individuals respond to insults such as disease and sexual abuse.
For example, a widely held belief among black SA women is
that large people are happy and healthy, whereas those who are
slender are perceived to experience personal problems and that
they may have diseases such as HIV/AIDS.
92
Furthermore, Goedecke
et al
.
93
demonstrated that ethnicity
altered the relationship between childhood sexual abuse and
obesity. In this small study, white women who were sexually
abused as children were more likely to be obese as adults. As
obesity is viewed as less attractive, this has been suggested
to protect against future sexual advances/abuses. By contrast,
black women who were sexually abused as children were more
likely to be lean, which was suggested as a means of protecting
themselves from further abuse. Furthermore, other studies have
reported that large women are respected, dignified and cannot be
pushed around.
32,94
The influence of family and community also alters body
size and satisfaction. For example, once a woman marries, she
is encouraged to gain weight as this signifies her husband’s
ability to support her financially.
32
In addition, the mother of
the household is expected to be an authoritative figure capable
of commanding respect from her children.
36
This, combined
with the expectation by black SA communities that people in
positions of power should be big, promotes the adoption of
higher degrees of tolerance for an increased body size. Puoane
et al
.
32
conducted a study on SA community health workers, who
are respected and important members of the community and
who play an important role in assisting with the communication
between the community and the formal health sector, and found
that 95% were overweight or obese.
Given that media influences extend further into disadvantaged
areas as the economy improves, black SA women are increasingly
exposed to conflicting body size ideals. Future studies should
therefore monitor the effect of such influences on body size
preferences.
Conclusion
There is compelling evidence that the prevalence of obesity is
increasing in SSA, and that this increase is linked to urbanisation,
economic development and concomitant lifestyle risk factors,
such as physical inactivity and poor dietary practices. In addition,
there are a number of paradoxes that have emerged, including the
positive association between food insecurity and obesity, the
non-linear association between education and obesity, as well
as the distinct differences between patterns and determinants of
obesity in men and women in the region.
Although this was not a systematic review, which may be
considered a limitation, this review highlights the complexity
of various socio-cultural, environmental and behavioural factors
associated with obesity in black SA women. Public health
interventions targeted at individual behavioural risk factors,
although important, may have limited success in reducing
obesity if other contributing factors such as culture, environment
and socio-economic status are not considered.
Key messages
•
The prevalence of obesity is increasing in SSA, and is linked
to urbanisation, economic development, and concomitant
lifestyle risk factors, such as physical inactivity and poor
dietary practices.
•
Socio-cultural, environmental and behavioural factors, as
well as the influence of socio-economic status, contribute
significantly to the high prevalence of obesity in black SA
women.
•
Barriers to physical activity in black SA women include
culture, socio-economic status and the built environment.
•
Food insecurity and dietary quality contribute to the preva-
lence of obesity in SA.
References
1.
WHO. World Health Statistics 2008. US Patent Office, 2008.
2.
Dalal S, Beunza JJ, Volmink J, Adebamowo C, Bajunirwe F, Njelekela
M,
et al.
Non-communicable diseases in sub-Saharan Africa: what we
know now.
Int J Epidemiol
2011;
40
: 885–901.
3.
Ziraba AK, Fotso JC, Ochako R. Overweight and obesity in urban
Africa: A problem of the rich or the poor?
BMC Public Health
2009;
9
: 465–478.
4.
Abubakari AR, Lauder W, Agyemang C, Jones M, Kirk A, Bhopal RS.
