The fat of the land
When Victoria Bowden’s obesity threatened her life, she opted for the drastic measure of surgery to reduce her stomach size to try to cut her weight from 167kgs.
‘I could hardly walk to the bathroom and back much less walk across the street. I could not fit in most booths if I ever did get to go out to eat, and forget the movie seats altogether. I was a self-imposed recluse. I was on two blood pressure pills, I was asthmatic and diabetic, I was also in congestive heart failure, had urinary incontinence. My veins were collapsing from God knows what. I knew my days were numbered,’ says Victoria, from Okmulgee in the US, in a note to the Association for Morbid Obesity Support (see www.obesityhelp.com.).
For Victoria (who shed 54kg after surgery) and others considered ‘morbidly obese’, operations such as ‘gastric bypasses’ are about the only way that they can reverse their extreme obesity and reduce the threat of the life-threatening illnesses it brings with it.
But really fat people like Victoria live in America not Africa, right? Unfortunately, not any more. Gastric bypasses are already being performed in Gauteng and Cape Town as South Africa’s obesity rate soars and a staggering 46% of women between the ages of 45 and 64 are considered to be obese. Obesity is defined as a body mass index (BMI) of over 30. (See box to calculate your BMI)
Tragically, malnourished children are at a greater risk than normal weight kids of becoming obese adults as their bodies, used to famine, immediately store food in times of excess.
Because obesity has long been associated with rich countries, it has been under-diagnosed and under-treated in South Africa. But it is growing exponentially, thanks to poor eating habits, too little exercise and, in some cases, ‘fat’ genes.
‘We are following the worldwide trend of increased obesity,’ says Professor Tessa van der Merwe, secretary of the International Association for the Study of Obesity.
‘This is being fed by the increase in fast food outlets, people eating more dense food and drinking liquid-based sugar and a decrease in exercise-based leisure, perhaps influenced by television and computers,’ adds Van der Merwe, an endocrinologist at Wits University.
As usual, the heaviest burden falls on women, with urban African women topping the scale. Over half of all South African women are overweight, and almost a third of these are obese, according to the 1998 Demographic and Health Survey.
Men and children are also at risk. The heaviest men are older, white and living in urban areas. A recent schools survey found that 17% school children between the ages of 13 and 17 were overweight. Indian and white kids from urban areas were the fattest.
Being overweight is not just a cosmetic issue, but brings with it serious health risks, says Dr Nelia Steyn, the Medical Research Council’s obesity expert.
‘Obesity usually comes first, followed by hypertension [high blood pressure] as the heart has to work much harder to pump blood around,’ says Steyn. ‘If these are accompanied by an unhealthy diet, lack of exercise and smoking it can also result in heart disease and diabetes. Death from stroke is one of the major causes of death in Africans, mainly from uncontrolled hypertension. Type 2 [non-insulin dependent] diabetes can be prevented by a healthy lifestyle with plenty of exercise.’
Infertility, arthritis, osteoporosis, joint pain, back pain, knee problems, breathing problems and sleep apnea (when a person stops breathing for short periods while sleeping), depression and low self-esteem are other common problems..
While diet and exercise are important weapons, Van der Merwe believes it is ‘most irresponsible’ of governments to simply describe obesity as a ‘lifestyle’ disease that can be solved by an obese individual dieting and exercising. In any event, in the case of the morbidly obese, ‘no lifestyle modification or prescription drugs’ are likely to work.
She believes instead that government intervention is needed along the same lines the anti-smoking measures. For as the tobacco industry has done, so too are soft drink and fast food companies now targeting the developing world.
‘The Western market is already saturated,’ says Van der Merwe. ‘People in the US are ingesting 80kg of sugar a year, in comparison to just 4kg in Kenya. The soft drink companies are marketing their drinks as the cheapest form of energy supply to the developing world. But our bodies find it very difficult to deal with sugar in a liquid form. Soft drinks are directly driving the obesity epidemic in the developing world. In order for government to address obesity properly, it needs to come up with legislative responses.’
She is in favour of higher taxes on unhealthy fast foods, as is the case with cigarettes; limiting the marketing of unhealthy foods to children and tighter nutritional labelling on foods.
Dr Thandi Puoane, who has been working to improve the health of urban African women for the past three years, says clear government policies targeting unhealthy foods ‘would help a lot’ to stop the promotion of unhealthy fast foods and fizzy drinks through aspirational advertisements.
A change in diet and a less active urban life has brought about an explosion of high blood pressure and diabetes, particularly among older African women. But the solutions are far from simple.
‘Many black women don’t want to lose weight because of the belief that an African woman is admired if she is a bit round. If a woman loses weight, there is also a perception that she might have HIV or her husband is not treating her well. So it is very difficult, once a person is overweight, to reverse this,’ says Puoane, who is based at the University of the Western Cape’s School of Public Health.
For the past three years, Puoane and colleagues have been educating community health worker volunteers in Khayelitsha about how healthy lifestyles can combat the diabetes and high blood pressure. These health workers are then encouraged to talk to people in their neighbourhoods about healthy choices.
‘Because of the cultural barriers, we don’t talk about losing weight. But we do talk about healthy eating and exercise,’ says Puoane.
But again there are barriers. Meat is associated with well-being, and many township residents want to eat it regularly but can only afford unhealthy fatty meat.
Resistance to exercise is another barrier. ‘People often come from rural areas where they have to walk to survive. They don’t see walking as something to do when you have time off. Also, it is not safe for women to walk around and there is a lack of space. We have started a walking club, and we hope people will be encouraged to join it when they see us walking around. But these perceptions are very, very difficult to change,’ she says.
Aside from the cultural barriers to losing weight, there are also psychological barriers. Even people who have had gastric bypasses can regain all the weight they initially lost because they have not addressed the underlying reasons for their overeating.
Initially, only anorexia and bulimia were classified as eating disorders but now binge eating is also recognised as part of the clinical diagnosis. While Cape Town therapist Joy Raine stresses that not all obese people have eating disorders, she says that many obese people that she has seen ‘feel fragile and vulnerable and their fat provides them with a suit of armour’.
‘If a person feels this way, weight loss from diet and exercise alone won’t be sustained. They need to understand the underlying causes of their behaviour in order to lose weight,’ says Raine.
Many of Raine’s patients come from homes where their childhood feelings were not acknowledged. ‘They have become numb, cut off from their feelings. And their feelings have been exiled to one place: their fat. It takes a lot of practice from when you are little to be able to manage your feelings, both good and bad. If a person hasn’t had their feelings heard and understood as a child, they internalise a sense that feelings are bad and no one wants to hear about them. This leads to the splitting off of feelings, because feelings seem to be unmanageable as well as wrong or bad.’
‘B’ who describes herself as a ‘compulsive binge eater’, confirms Raine’s view. She says she was surprised when her doctor recommended that she join Overeaters Anonymous because she overate for emotional reasons. ‘Overeating for emotional reasons was news to me. I didn’t have emotions. I was never angry, sad or lonely, only constantly hungry,’ writes B, in the Overeaters Anonymous magazine, Lifestyle (see www.oa.org).
It was only once B acknowledged that her husband had verbally abused her for 20 years, that she was able to implement the Overeaters programme (based on the 12 steps programme for addiction) and address her binge eating.
‘Once my patients have been able to start incorporating feelings in their lives, their weight starts coming off,’ says Raine.
Debbie Nash, head of the therapy unit at the Kenilworth Clinic for Eating Disorders in Cape Town, says that food can become a source of comfort for children who need nurturing, perhaps because their parents are over-critical, distant or absent. She also says that overeating can be a refuge for older women who feel disempowered in their families.
Obesity and its consequences are costly, both to individuals ‘ who are often laughed at and shunned ‘ and to the health system. But inevitably, prevention is a lot easier than cure. And that means targeting children.
Late last year, a US Congressional task team issued an action plan aimed at addressing obesity in children. Cornerstones of the plan are that children should do at an hour’s exercise every day, their television and computer time be limited to a daily maximum of two hours, that soft drink and snack machines at schools should be regulated and that those marketing junk food should voluntarily limit advertising to children.
In this country, Dr Karen Sharwood of the University of Cape Town’s Unit for Exercise Science and Sport Medicine is driving a national campaign for a Charter for Physical Activity and Sport for Children and Youth. Less than a third of African kids in Johannesburg are offered PE at school, according to the Wits Birth to Twenty study.
‘This charter is being developed as a result of concern from parents and teachers at the increase in obesity, which has far-reaching consequences for our health and for the cost of healthcare,’ says Sharwood. ‘We want the charter to provide the philosophical guidelines for exercise and sport in South Africa.’
The draft charter is based on the premise that all South African children have the right to play sport in safe environments, and that physical activity and sport are essential for growth, personal development and socialisation.
Combined with life skills at schools to help children to deal with emotional problems and stress without resorting to overeating, the charter provides one concrete way to prevent today’s fat little kids from ending up under the surgeon’s knife after a lifetime of failed diets. ‘ Health-e News Service.
* Sharwood can be contacted on 082 576 6554.
Calculating your BMI
BMI = Weight in Kilograms
(Height in Meters) x (Height in Meters
(Divide your weight in kg by your height in metres multiplied by itself)
BMI is a guide and has a number of limitations. It is not suitable for children. It also overestimates body fat in athletes and those with muscular builds, while it underestimates body fat in older people and others who have lost muscle mass.
Your child is likely to be overweight if s/he has a body mass index that is above the 95th percentile for his or her age group.
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