Class of 2017: Kufre Okop’s research shows body image attitudes are contributing to SA obesity issues
The determinants of obesity are reasonably well known: the usual suspects of diet, physical inactivity and socio-economics. Across the globe, all of these have been targeted in intervention efforts, but with only limited results, says says Dr Kufre Okop, who graduated this year with a doctorate in public health from the University of the Western Cape (UWC).
In his doctoral work, Okop wanted to explore some of the social, environmental, familial and psychological factors that play a part in obesity and may make individuals and communities more unwilling to shed the weight.
More specifically he wanted to look at a key determinant: body image, as shaped by the dominant culture in a society, and its association with body fat and total cardiovascular disease.
In South Africa, many African women and men carrying extra weight do not think of themselves as obese or at risk of obesity – quite the contrary, they consider their surplus pounds desirable and essential for their social standing. That is a big concern for a country with South Africa’s growing obesity problems.
Increased body weight is associated with cardiovascular diseases (CVD) like hypertension (high blood pressure), ischaemic stroke and ischaemic heart disease (ischaemic refers to blood flow to organs and tissue), as well as type 2 diabetes among South Africans aged 15 years and older.
As Okop points out in his thesis, CVD is now recognised as the second largest cause of death in South Africa after HIV/AIDS/TB, rising from about 13.2% in 1997 to 17.8% in 2010. And excess body weight (a body mass index, or BMI, over 25) has in studies been linked to 87% of cases of type 2 diabetes, 38% of heart disease, and 45% of strokes in the country. What’s more, the prevalence of excess weight and obesity has risen sharply in South Africa - a disconcerting spike from 56% to 65% between 2002 and 2012. (Anyone with a BMI between 25 and 29 is considered overweight; those with a BMI over 30 are classified as obese.)
There are noticeable gender and ethnic differences among South Africa’s overweight and obese population. One study showed that even higher proportions of black men (49.3%) and black women (74.6%) were overweight or obese than the men (45.7%) and women (66%) of mixed ancestry (i.e. coloureds), and white women (42.2%).
These numbers spell trouble for individuals.
But why the difference? What role does body image play? And what can be done about it?
To investigate these issues, Dr Okop incorporated his own study into the South African arm of the global Perspective Urban and Rural Epidemiology (PURE) study, involving groups in rural and urban Western Cape and Eastern Cape. There he weighed, measured and interviewed black men and women aged 35-70 years.
His findings indicated a sustained (over 2010 to 2015) high obesity rate in the black South African cohort that he studied, not only among women (as often reported in earlier studies), but among the men as well.
A high level of obesity - based on three indicators for ‘adiposity’ (commonly referred to as morbid obesity), namely BMI, BF% and waist circumference (considered a better indicator of health risks) - was reported among men in both rural and urban communities than had previously been reported.
Okop also showed that the prevalence of excessive body fat in women and men is “extremely high” - 9 out of 10 women and 6 out of 10 men in his study group had excess body fat percentage (BF%). But ultimately, Okop wanted to get a sense of how much body image is contributing to these troubles.
Body Image and Overweight: Why worry?
Literature suggests that across Sub-Saharan Africa, a ‘fat’ or overweight body size is idealised for women - and men.
In many African communities, for instance, a newly-married woman is expected to quickly put on weight, to prove to the in-laws and the community that her husband is taking good care of her, explains Okop. For both men and women, the extra weight they carry is an indicator of affluence, good health, happiness, beauty and influence. Among men, the ‘big size’ is considered important for commanding influence and power.
“Body image preference and accompanying problems are not only seen in Africa but globally, even in the US; several studies have documented this,” says Okop. “The difference is that, in the developed western world, most women prefer slender size or shape, whereas in African settings like South Africa, large body sizes and shapes are often preferred, particularly among black women and men.”
Such is that influence that there is stigma attached to being thin - in contrast to the developed world, where obesity is typically stigmatised.
“In the face of HIV/AIDS and TB epidemics in Africa, if you are thin or slender, then you are often considered to be sick of HIV/AIDS or even cancer,” notes Okop.
Body image perception is also associated with other ills, he pointed out in his study. For instance, negative body image has been shown to play a role in the uptake and rise of smoking among adolescents in non-African populations.
The clear and present danger, of course, is to South Africa’s black population - especially as it goes hand in hand with changing dietary habits.
Okop’s main doctoral supervisor, Professor Thandi Puoane of the School of Public Health at UWC, has in her studies shown that changes in black urban and rural diets have in large part been brought about by the rise of ‘big food’, notably fast-food and supermarket chains, driving people towards more affordable foods with high fat and sugar content.
“Many more people are getting overweight or obese every year, due to the current nutrition transition - a shift from African types of food to westernised high-fat high-calorie food - and easy access to cheap sugar-sweetened beverages,” says Okop.
“The synergistic effect of nutrition transition, increasing access to junk food and the dominant cultural preference for large body image among the majority of black South Africans is a great public challenge as this not only impacts on weight management, but on self-management of diseases such as diabetes and hypertension.”
Worryingly, most overweight and obese women were not willing to lose weight, as they considered being overweight ‘not a health risk’, reports Okop - in the qualitative part of his study in which he interviewed a number of men and women.
In the face of the health risks of excess weight, Okop recommends that interventions to reduce obesity and mitigate cardiovascular disease mortality risk in black South African communities should address the discrepancies in weight perception, poor obesity risk perception, and personal motivation towards weight loss.
Ideas on what represents a healthy weight may have to be changed, so that black men and women may be convinced to shake off the extra pounds and avert weight-related health problems.