IJE Advance Access originally published online on October 27, 2005
International Journal of Epidemiology 2006 35(1):24-30; doi:10.1093/ije/dyi204
Published by Oxford University Press on behalf of the International Epidemiological Association © The Author 2005; all rights reserved.
Obesity amidst poverty
Felicia Webb,
Andrew Prentice and
Felicia Webb*
* Corresponding author. felicia.webb{at}virgin.net
The Gambia is in the early phases of demographic transition. Globalization is changing diets and lifestyles. Rural livelihoods have become virtually unsustainable following the collapse of groundnuts as a cash crop owing to external competition. This encourages urban drift and transnational migration. Sedentary occupations and plentiful high-fat diets are causing burgeoning obesity in urban areas. Even in remote rural areas remittance payments from those in the city or abroad have increased purchasing power, and cheap imported vegetable oils are a major commodity in local shops. Obesity—at one time confined to the area chief and his wives—is now rapidly spreading throughout the countryside. And this pattern is being repeated throughout the developing world—bringing with it a new burden of debilitating and costly chronic diseases.
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URBAN Mama: ‘I have high blood pressure. I've never been to the doctor but I know because my head hurts. My father had diabetes, he died of it, but I've never been tested. I don't like to be big, it troubles me. If you walk just over there and then you sit down you feel your heart pounding. I'd like to halve my weight.’
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RURAL Diets in rural Gambia are considered meagre by urban dwellers. Large quantities of rice, maize, or millet are topped by a groundnut or leaf sauce and a small fish or two to be shared among many. But even here remittance payments from overseas family members are rapidly increasing purchasing power. The yellow plastic containers from imported oils have replaced kerosene cans as the ubiquitous water container.
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URBAN Bintou's ‘fastfood’ stall in Banjul market has vast bowls of benechin (rice and meat cooked in oil), plassas (a palm oil stew), domoda (an oily groundnut sauce), chicken yassa, and the like. Oils, fats, and meat are prized above all, and portion sizes are large.
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RURAL After a hard day in the distant fields, walking home with a child on her back and firewood on her head, Sibi still has to prepare the evening meal from scratch by shelling a few groundnuts and pounding rice or millet. Up to now farm work and frugal diets have kept rural Africans lean and free from the diseases of affluence—but this is set to change.
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URBAN Mama and friends congregate on the beach at Bakau fish market to fillet their husbands' catch. In some urban areas it is difficult to find a non-obese woman. Africans are much more tolerant of obesity especially among middle-aged women. It is a status symbol worn with panache and elegance. Yet there is a high awareness of the medical risks.
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URBAN Ya Hadi and her brother Dudu. A recent survey of urban middle-aged Gambians revealed that 36% of women were obese (BMI > 30 kg/m2) but only 2% of men. Women have constant access to food when cooking and fat women are considered beautiful. Under-the-counter sales of steroids from pharmacies are regularly used to ‘put on body’ by younger women.
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URBAN At present men are a rare sight in the queue for the diabetic clinic at Banjul's main hospital, but as the epidemic of obesity continues men will also be affected. Presently it tends to be the wealthy, but in another generation it will be the poor that suffer most.
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URBAN The other side of the picture: malnutrition and obesity coexist in neighbouring wards in the Royal Victoria Teaching Hospital. Over half the children admitted to the hospital show signs of malnutrition. Most frequently marasmus and kwashiorkor are caused by the effects of diarrhoeal diseases rather than absolute poverty. The rehabilitation of a malnourished child takes several weeks in the specialist ward.
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URBAN A dual burden of disease: like many emerging nations The Gambia is having to cope with the unfinished agenda of infectious diseases and the emerging agenda of non-communicable diseases. Surgeons list amputations of diabetic feet as one of the most common procedures. The additional strain on already over-stretched health delivery systems is critical. In sub-Saharan Africa case-specific mortality rates for diabetes are over 10-fold higher than in the UK.
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RURAL Mariama lives in Likunda, the richest compound in Keneba. The family own most of the cattle in the village. ‘I eat a lot and whenever I eat I do a lot of work, I have a reputation for strength in the field, and as we all know there is no livelihood in Keneba other than hard work.’
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RURAL Ten-year-old Aja (right of picture) and her sister, Nyimansata, stand out as the fat children in Keneba. Aja's father: ‘Both my wife and I had body when we were younger so maybe it's because of this that they are fat. Bigger people are thought to be rich. I was proud to be called fat. When Aja goes out people tell her she is fat and it upsets her and she will fight. Aja comes home crying and I reassure her that they're just playing. I'm not worried because they never complain about pain in their body.’
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RURAL Mariama: ‘Day after day if there's food I'll eat it. I want to maintain my weight because it doesn't disturb me. I feel better than thin women, I feel sorry for them. My babies have always been big and healthy.’
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URBAN Ya Hadi: ‘It's not good, everyone who has body doesn't want it, those who do it's stupidness, just stupidness. Body is suffering, not good, body gets diabetes, high blood or other sickness. Anyone who wants body doesn't know. Everything makes you tired when you are fat. I get heat so much, my legs pain me so much, even if I'm sitting down my knees hurt so much, so much pain. In our family we all have body, we are six women and we all have body. I want to lose.’
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Photographer Felicia Webb won the 2004 NPPA-Nikon Documentary
Sabbatical Award for her studies of obesity in children in Houston,
USA. She is now expanding this project into a global photo-essay.
With the support of a Travel Fellowship from the Winston Churchill
Memorial Trust she recently visited Gambia to investigate how
the obesity pandemic affects both urban and rural communities
in sub-Saharan Africa.
Andrew Prentice is Professor of International Nutrition at the London School of Hygiene and Tropical Medicine, and scientific director of the Medical Research Council's Keneba field station and of the nutrition programme for MRC Laboratories, The Gambia.
All images copyright Felicia Webb, text copyright Andrew Prentice and Felicia Webb.
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