South Africa’s obesity crisis: the shape of things to come?
Published by Mosaic Science (9th September, 2014)
When the first McDonald’s restaurant opened almost two decades ago in Johannesburg, a teenage boy named Thando Tshabalala was among the thousands who stood in line patiently waiting to try one of those famous burgers. “We had seen this place in every movie we ever watched, and it seemed to be mentioned in every song, so I had to try it for myself,” he said.
Given such enthusiasm, it was hardly surprising South Africa proved to be fertile territory for the burger chain, breaking expansion records with 30 outlets opening in under two years. Today the company operates more than 200 restaurants across the country. Yet when arch-rival Burger King finally entered the market last year it was greeted with similar excitable scenes as almost 5,000 people descended on its launch branch in Cape Town, some even sleeping on the street to ensure they got their hands on a Whopper. “We did not expect the demand to be so great,” its chairman confessed later.
Tshabalala, now a successful 33-year-old corporate trainer, still enjoys fast food. Indeed, when we met he was eating a steak sandwich in the food court of a smart shopping mall, sitting among scores of shoppers and families feasting on curries, pizzas, fried fish and the ubiquitous chips. But that skinny teenager has grown into a five-and-a-half-foot-tall man weighing almost 17 stone – and today he struggles to find clothes to fit his inflated body and complains seats are becoming too small for comfort.
“To be honest, I feel rather self-conscious about my size,” Tshabalala told me with a rueful smile, adding that part of the problem was spending so much time on the road with his job. “There is this saying in South Africa that if you have a one-pack belly, like a beer belly, you must have lots of money but if you have a six-pack there is something wrong. But I know it is not really a sign of success to have a big belly.”
Sitting with him was his girlfriend, Fiona Sefara, an entrepreneur building a recycling business. A former vegetarian, she recalled leaving South Africa before the end of apartheid to go and live in the United States. “When I went there I was surprised to see all these overweight people on the streets – but when I came back home, McDonald’s was everywhere and there were all these bigger people on our own streets.”
As we chatted, she chided her partner for his fondness for fried food and huge portions, then confided that the worst aspect of the change in her homeland was seeing so many overweight children. “We had nothing as children so would take a tennis ball outside and play for hours until it was dark. But now they have computers and are driven everywhere,” she said. “My own nephew is so chubby that he has become one of those American kids.”
But these are South African kids. And they live in a country that has a growing problem with obesity, like many other parts of the African continent. For fat is no longer just a rich-country problem. Forget those tired old clichés beloved by the aid industry: today, more people in poorer countries go to bed each night having consumed too many calories than go to bed hungry, a revelation that underlines the breakneck pace of change on our planet.
This astonishing fact was revealed in a landmark report by the Overseas Development Institute earlier this year. It showed that more than one-third of the world’s adults are overweight – and, surprisingly, that almost two-thirds of the world’s overweight people are found in low- and middle-income nations. The number of obese or overweight people in these countries rose from 250 million to almost one billion in under three decades – and these rates are rising significantly faster than in rich nations.
South Africa is a leader in this alarming new trend, with an obesity rate nearly double the global average and, according to another report, becoming the world’s third-fattest nation. Approaching two-thirds of the population are overweight – and, unlike in the developed world, the problem affects more women than men. Incredibly, 69.3 per cent of South African women have unhealthy levels of body fat and more than four in ten are clinically obese.
These findings emerged in a Lancet study published in May, which analysed data over a 33-year span from 188 countries. It found the rise in global obesity rates was “rapid, substantial and widespread, presenting a major public health epidemic in both the developed and developing world”. Obesity is on the rise in poorer nations even among children; more than a quarter of girls and almost a fifth of boys in South Africa are overweight, for example.
“These are devastating figures, especially since it is such an expensive disease,” said Professor Tess Van der Merwe, who performs weight-loss surgery and is Chair of the South African Society for Obesity and Metabolism. “We simply cannot afford to spend the next decade debating this issue. The obesity problem in our country is where the HIV epidemic was ten years ago when we turned a blind eye to the scale of the problem in terms of health economics and became the worst in the world in terms of outcomes.”
Terrifying talk for a nation in transition that provides only rudimentary healthcare for most of its population and where a quarter of citizens still struggle with food security. The result is that while one in five children under ten years old suffer stunting due to long-term malnutrition, millions of adults are falling victim to diseases associated with prosperity, such as cancer, cardiovascular conditions and diabetes.
Experts say such diseases will soon overtake HIV and tuberculosis as the biggest causes of death in South Africa, following the global trend of lifestyle conditions causing a majority of fatalities. The United Nations already predicts that by the end of the next decade non-communicable diseases will kill nearly five times as many people worldwide as infectious scourges such as AIDS and malaria, which have caused carnage in poorer parts of the planet.
And South Africa seems to be merely leading the way in a health crisis creeping across the continent, challenging conventional Western views of it as a place riddled with famine. The Lancet study found that more than half the women in Botswana and one in eight Nigerian men are also obese, for example, while Egypt saw one of the fastest rises among women. Little wonder the World Health Organization predicts cases of obesity-driven diabetes will double across sub-Saharan Africa in the next 20 years – although a few parts of Africa, including Burundi, Ethiopia and Rwanda, still remain largely immune to the obesity crisis.
One man who understands the scale of South Africa’s challenge is Aaron Motsoaledi, a 56-year-old doctor from Limpopo and the country’s current minister of health. “It is weird when we are seeing malnutrition coexist alongside obesity,” he told me. “I am not only sad but alarmed because of my medical training. I know the consequences of obesity – it turns into more kidney disease, more heart problems, more diabetes. The costs are going to be very high. In the next decade many countries are not going to be able to afford their health costs and this definitely includes South Africa.”
Motsoaledi believes the problems fit a global pattern of obesity caused by the rapid shift to urban living combined with increased consumption of Western-style diets high in sugar, fat and salt. The problem is worsened in South Africa since it is a nation with a love of meat barbecued on the braai, cutting across ethnic boundaries; the two groups hit hardest by obesity are white Afrikaner males and black urban females. On top of this, fear of crime has boosted car culture, with cities designed around US-style shopping malls and fewer children running free in the streets.
“You have to remember that 30 years ago black people in South Africa were eating produce from fields that was much healthier and they were walking big distances,” said Motsoaledi. ‘When I was a child pupils would regularly walk six kilometres to school; some even walked ten kilometres each way. Now life has changed and people do not want to walk anywhere.”
The health minister tries to set an example, dropping a couple of clothes sizes after cutting down on meat and eating more fish and vegetables. But not all the country’s political leaders are so diligent; last year there was a scandal after it was discovered the premier of one province used her government credit card to spend nearly £3,000 on fast food in her first ten weeks in office, at outlets such as Kentucky Fried Chicken and Wimpy. Other MPs have moaned about huge portions of unhealthy food served in parliament making them fat.
Motsoaledi complains that he is dismissed as a health fanatic while food companies chasing profits simply ignore his attempts at regulation. Yet clearly the country is waking up, slowly, to the scale of the crisis, with fat police officers ordered to shape up if they want to stay in uniform and radio hosts highlighting healthy living. Attempts to grapple with this obesity epidemic, however, show the special problems this global concern causes among poorer people in developing nations.
To understand this, I drove one sunny Monday morning to visit Petrus Molefe Park in Soweto, named after a local hero of the liberation struggle. Two years ago the city council installed an impressive ‘green gym’ among the immaculately clipped lawns to encourage residents to get fit. Sure enough, the first person I met was the perfect promoter for the idea: an unemployed man named Vusi, who told me he spent two hours every day pumping iron after abandoning his unhealthy lifestyle and shedding several pounds.
Then we were joined by three young women, who confessed that this was the first time they had come along, in a bid to lose weight. I started talking to Octavia Mphumbude, tentatively testing a running machine in her turquoise jeans and black cardigan. “I won’t lie – I like junk food a lot,” said the 25-year-old single mother, who has never managed to find a job in her life despite intensive efforts and voluntary work. “The trouble is that when I am hungry I crave fast food. It is hard to resist. And many of the women around here are unemployed like me, so if you are unhappy it is comfort food. This is why weight is an issue for us.”
Unfortunately, poor people fill their bellies with cheap food – and this often means salt-drenched starchy carbohydrates, highly processed sweetened products and the fattiest cuts of meat discarded by wealthier consumers. Street-food surveys found that chicken sold in townships is often little more than skin and that other meat is just fatty offal, while foreign fast food is seen as sophisticated. Meanwhile mothers go without meals to ensure their children eat, then gorge when they have money.
All this can led to ‘hidden hunger’, when people eat regularly and even put on weight but lack nutrients and vitamins needed by their bodies, leading to long-term health damage. “In one household you can see children who are undernourished, the man with normal weight and then the wife who may be heavily overweight,” said Zandile Mchiza, an expert with the Chronic Diseases of Lifestyle Unit at the Medical Research Council. “This is why we have the issue of obesity coming up so strongly in Africa even as many people are still starving.”
Mchiza also pointed to cultural issues that fuel obesity in Africa, with big men seen as successful and big women seen as beautiful. “The majority of black South African men prefer chubby women. If your cheekbones are showing then you are not beautiful in our culture,” said the 34-year-old scientist. “If you are too thin then it means your husband is not taking care of you or you are unhappy. And your children must be fat too – I remember we were force-fed growing up, always told to eat up all our food and not waste anything on our plates.”
I heard similar claims from several other experts – and certainly a glance at the internet indicates specialist dating sites for “cuddly” people seem to be booming. A study last year by the Human Sciences Research Council found 88 per cent of South Africans regard a fat body as their ideal, and most people see no need to change their lifestyle. But Mchiza believes traditional attitudes are slowly changing as cultures meld together in cities and the country is influenced by differing global perceptions of beauty. “Urbanised women of black ethnicity are becoming dissatisfied with their body size,” said Mchiza. “But it is very difficult to hasten cultural change.”
Clearly this corrosive concept that fat is a sign of success still clings on in South Africa, as in some other countries on the continent, although many people I spoke with seemed to know it was a myth. “I am big not because I am wealthy but because I have problems with money,” said Christabel Ntomuifuthi, 45, squished into a plastic chair beside communal vegetable gardens in Orange Farm, an informal settlement about 30 miles from Johannesburg. “I eat all the time just so I am full of something but it is not healthy.”
We talked beside lovingly tended plots of spinach, peas, beetroot, rosemary and onions, created on land reclaimed from carjackers who once burned stolen vehicles there. The city council wants to ensure some squatters can earn cash while eating more healthily – but for all their efforts, Ntomuifuthi showed the difficulty of changing attitudes. “If I had money I would eat meat Monday to Monday because I love it so much, although my weight is already too much,” she said, roaring with laughter. “I would eat lots of T-bone steaks and McDonald’s.”
Several other township women mentioned another depressing reason not to diet. “There is a stigma that if you are a black woman and start losing weight you might be ill, that you might have HIV,” said Dudu Masooana, a friendly 38-year-old mother of three from Soweto whom I met as she lunched on fried chicken and pap, a traditional porridge made from ground maize. “This really matters if you are a woman coming from the ghetto.”
Masooana had also bought a ‘bunny chow’ on her way to work – a popular and filling street food made of hollowed-out bread loaf stuffed with curry, a legacy of the apartheid era when Indians, along with black people, were banned from many shops and restaurants. After our discussion of diet, she told me she would give it to one of the poorly paid security guards at the busy shopping mall where she was employed, since they often missed meals.
Although research is crippled by a lack of reliable historical data, recent studies indicate obesity rates in South Africa growing even faster than those in the Western world. Alarmingly, it is estimated an obese person takes up at least 25 per cent more healthcare spending than someone of average weight.
To give just one example of the impact, there has been a 12–15 per cent surge in diabetes in five years, with 6.5m identified cases and an estimated 2m unidentified ones, leading to a sharp rise in leg amputations, blindness and kidney failure. “This increase is remarkable and horrific,” said Razana Allie, a nurse educator and spokeswoman for the Diabetes Education Society of South Africa. “We are a rising nation but we have to face up to the impact of diabetes on our economy.”
A horde of parasitical industries have grown up to feed off the crisis, from quack diets and hypnotism at one end of the spectrum to fitness boot camps and bariatric surgery at the other. For the most extreme cases, about 1,000 gastric band operations are performed annually in the private sector; they cost close to £10,000. Practitioners argue they should be extended to the public sector given their good success rates with morbidly obese patients, who are difficult and expensive to treat since their problems move way beyond lifestyles into deep realms of psychology and addiction.
Television has also got in on the act, with reality shows encouraging people to turn their lives around by exercising and improving diet. One of the most popular is Kabelo’s Boot Camp, hosted by a pop star who became a poster boy for healthy living after defeating a drug problem and losing 100 pounds. Now Kabelo Mabalane runs marathons, eschews substance abuse, eats properly, and on his show puts ten South Africans through their paces, selected from the thousands of hefty applicants.
“We used to associate wealth with a big tummy and had the idea that if you were skinny you were not doing well,” he told me. “It is only now, 20 years after democracy, that we are dealing with these issues and educating people about the dangers of overeating and obesity. We know it is a physical transformation but you have to deal with the issues inside the head too.”
Runner-up on the first series was Cecilia Mashinini, 26, logistics controller for a drugs firm, who lost more than four stone during recording. She told me of her misery growing up as a fat girl in Alexandra township, the legacy of her father running a food shop. “He used to give me all the food he had left over to show his love but he was not aware of what he was creating,” she said. “Like every woman I never wanted to be the fat friend, and just saw thin people everywhere on television, then the more depressed I became the more I ate.”
Walking down the street Mashinini was routinely subjected to taunts of “Hey bomba” (‘fatty’) – they “killed me inside” every time, she said. She hated shopping for clothes and binged at fast-food joints where no one she knew would see her. Now this chirpy character is a local celebrity, long-distance runner and inspiration to larger women in her community.
“The saddest thing is there are so many people starving in the townships who can’t afford healthy food and just eat what they can, so inevitably some of them become fat. But when you are fat no one takes you seriously – they just see someone they think wants to sit on the sofa all day and eat. They never see someone who might be smart and hard-working.”
The key question, of course, is how to turn this tide of obesity that is killing South Africans while weighing down the country’s fragile economy and healthcare system. “For decades we used to blame individuals,” said Leonie Joubert, a writer on food and hunger issues who had just returned from a mountain run when we spoke. “Now it is seen as a normal response to an abnormal environment. The system of urban living is making it harder and harder for people to make the right choices, with disastrous consequences.”
Joubert argues that our brains are hard-wired to seek out fat, salt and sugar. Given this, she believes the country needs to challenge the food firms, retailers and advertisers that are deliberately fuelling self-harming addictions to toxic substances, especially given the speed of change in a country where people are cutting ties with traditional lifestyles. “The bottom line is we all eat crap, which is why we need regulation,” she said. “There is no silver bullet because you have to look at broader issues about our food system, retailing set-ups and even capitalism itself.”
There are signs the government recognises the need for action, with the vice-president set to lead a commission bringing together academics and officials from different departments to find urgent solutions. The hope is to get the nation to take notice of the crisis; the outlawing of trans fats was simply ignored by the food industry and the government lacked the ability to police the measure. There has been action taken also to reduce salt in processed foods such as bread and talk of a ban on alcohol advertising, provoking outrage from a powerful industry.
But this is a global crisis. And the surge in South African obesity is simply one more sign that – from Cape Town to Cairo – a continent for too long seen as the poor relation is catching up with the rest of the world as it rapidly grows and urbanises. Obesity is growing faster globally than any other cause of disease. Mexico has rates to match the United States; the number of overweight people in China – a country that endured horrific famine within living memory – has near-doubled since 1980 as teenagers guzzle fast food and parents shower sweet treats on their solitary children.
There are attempts to grapple with this crisis: restricting trans-fatty acids in Denmark, imposing taxes on fizzy drinks in Mexico, even fines for employers of overweight staff in Japan. But there was one more chilling fact in that recent Lancet study looking at three decades of obesity around the world. Not only are one-third of the planet’s population too fat, the numbers rising daily and the problem hitting women especially hard – but perhaps most frighteningly of all, not one of the 188 nations studied managed to reduce obesity levels over the period studied. Truly, as the fast-food joints and shopping malls of South Africa show, this has become a global health and social crisis of gargantuan proportions.