Obesity in Women: Socio-Cultural and Nutritional Perspectives from Uganda

By Seera Georgina

The Double Burden of Malnutrition (DBM) has become a major global problem particularly in the so-called low- and middle-income countries (LMICs) because of the rapidly increasing prevalence of obesity and overweight, particularly in women as indicated by the Body Mass Index (BMI), alongside the slow decreases in the long-standing problems of hunger and childhood undernutrition. That BMI may underestimate the extent body fat and associated risks in some populations is well documented. However, the possibility for BMI to overestimate the degree of body fat and the associated health risks in some populations is not as well documented. In Uganda, and indeed in many countries in sub-Saharan Africa, screening for non-communicable disease (NCD) risk factors is not easily accessible for most people, and the prevalence of an increased health risk that is triggered by high BMI seems to be less than what is observed in other areas. This book details how women in Uganda have developed their own sense of an ideal body size which is not so small as to be associated with communicable disease, and not so fat as to put them at a risk for non-communicable disease; in a way that is different from the global standards. It further details the daily activities of women in urban Uganda as they pertain to physical activity level and energy requirement, as well as detailing how the past and present socioeconomic circumstances interact to shape women s food consumption practices, attitudes and beliefs; and how these might predispose women to obesity. Georgina Seera was conferred a Doctor of Area Studies degree, majoring in African Studies, from Kyoto University, Japan, in March 2021. Her research focuses on obesity and overweight in women, as well as the beliefs, attitudes, practices and daily lives of people in Uganda as they pertain to food.

• Language: English
• Publisher: Langaa RPCIG
• Release date: Feb 27, 2023
• ISBN: 9789956553136

Book preview

Chapter 1

Introduction: Global Burden of Malnutrition

1.1 Double Burden of Malnutrition

The biggest risk factors in the global burden of disease have been previously described as including: undernutrition; unsafe sex; high blood pressure; tobacco consumption; alcohol consumption; unsafe water, sanitation, and hygiene; iron deficiency; indoor smoke from solid fuels; high cholesterol and obesity. These factors put together account for more than a third of deaths all over the world (WHO 2002: 7). Noticeably, nine out of the ten factors are related to consumption – where a problem may arise from any one of the two extremes, i.e., too much consumption or too little consumption of food and other specific items (WHO 2002: 9).

‘Too little consumption of food’, usually occurs when food consumption is insufficient in relation to dietary requirements. It is described under the technical terms: ‘undernourishment’ at the population level; and ‘undernutrition’ at the individual level (FAO 2012: 5). Undernutrition can also occur when there is faltered absorption and assimilation of the nutrients in the body after food consumption. This often leads to distortions in the function of body systems and growth faltering in young children (Shrimpton and Rokx 2012: 3). The resulting deficiencies in essential macronutrients and micronutrients reduce an individual’s quality of life (WHO 2002: 52) and put the individual at an increased risk of adverse health consequences (FAO 2012: 5).

Too much food consumption is usually understood as being characterised by high food intake, particularly of empty calories, free sugar, refined carbohydrates and saturated fats, leading to gains in weight over the recommendations for a healthy life (WHO 2002: 60). The term ‘overnutrition’ is seldom used, but it theoretically encompasses what occurs when energy and nutrient intake exceeds the requirements of an individual also leading to distortions in body function and obesity or overweight (Shrimpton and Rokx 2012: 3).

Undernutrition and overnutrition are both defined in public health, primarily by poor anthropometric status (WHO 2002: 52). Three growth indicators based on the WHO’s 2006 child growth standards are used to assess for undernutrition among children under five years, namely, Height For Age (HFA), Weight For Height (WFH) and Weight For Age (WFA).

A low HFA is indicative of chronic or long-term undernutrition and is termed ‘stunting’ – defined as two standard deviations below the WHO child growth standards (WHO 2006). A low WFH characterised by rapid weight loss is indicative of acute, short-term, or current undernutrition and is termed ‘wasting’ – defined as two standard deviations below the WHO child growth standards. A high WFH is indicative of ‘overnutrition’ and is termed ‘overweight’ – defined as two standard deviations above the WHO child growth standards. ‘Obesity’ is defined as three standard deviations above the WHO child growth standards. A low WFA in children can be indicative of either chronic or acute undernutrition, or both, and is termed ‘underweight’ – defined as two standard deviations below the WHO child growth standards (FAO 2012: 5).

Suboptimum growth has been shown to increase the risk of morbidity and mortality from infectious diseases in childhood (Black et al. 2013: 438). The risk is significant in cases of both severe and mild undernutrition. In fact, less severe forms contribute most to the burden of deaths from undernutrition as they are the most prevalent forms (WHO 2002: 53).

Micronutrient deficiencies in both children and adults are characterised by the inadequate dietary intake of a specific vitamin or mineral. These deficiencies are not always accompanied by clinical symptoms. When tissue or serum levels of a given micronutrient are inadequate, the individual in question is deficient and at risk of health consequences. These include increased morbidity and mortality, poor reproductive health, impaired physical growth and cognitive function, among many others, depending on the specific micronutrient or combination of micronutrients.

Iron Deficiency Anaemia (IDA), Vitamin A Deficiency (VAD), and Iodine Deficiency (ID) are currently considered to be the micronutrients of the most public health significance in most places. Many countries have supplementation programmes for these micronutrients, particularly for women and children (FAO 2012: 5).

For children and adolescents in the 5–19 years old age group, WFH is not applicable, and WFA is only useful until they are 10 years old. HFA and Body Mass Index (BMI) For Age (BFA) are the preferred indicators for nutrition status among children and adolescents in this age group. BFA values below 2 standard deviations of the WHO’s 2006 child growth standards are indicative of undernutrition while values that are 1 and 2 standard deviations above the WHO child growth standards are indicative of overweight and obesity respectively.

The BMI is the most widely used indicator for assessing of undernutrition and overnutrition in adults. It is based on the ratio of weight in kilograms to the square of height in metres. It is independent of gender and age in adults and cut off values have been established. A BMI within the range of 18.50–24.99kg/m² is considered to be indicative of a normal weight. Chronic Energy Deficiency (CED), also known as underweight or thinness among adults is defined as BMI<18.5kg/m², overweight is defined as BMI≥ 25kg/m² and obesity as BMI≥30kg/m² (WHO 1995). BMI is not a perfect indicator, particularly for the distribution of body fat (Nuttall 2015: 121), but it shows a strong correlation to body fat content, and it provides a common benchmark for assessment and comparison (WHO 2002: 60). Together, ‘undernutrition’ and ‘overnutrition’ constitute the broad term ‘malnutrition’ (WHO 1995).

The consequences of malnutrition for both individuals and systems are numerous and far reaching. They have been elucidated in existing literature for several years now. It is impossible to list all of them here but they include the following: 1) countries with high rates of child and maternal undernutrition tend to concurrently experience high rates of infant, child and maternal mortality; 2) in utero and early life undernutrition are associated with about a third of young child deaths; 3) among the survivors who do not die in utero, as neonates or before their second birthday, many become stunted during the first two years of life; 4) consequently, their capacity to resist disease, to carry out physical work, to study and progress in school are all impaired across the life course; 5) later in the life course, these same children are more susceptible to overnutrition, i.e. obesity and overweight, metabolic syndrome and several other non-metabolic non-communicable diseases (NCDs) such as cancer.

These consequences of malnutrition can manifest at the individual level, across the life course of an individual, at the household level among different members of the household and at population level. It was observed that undernutrition and overnutrition did not always occur separately in different populations at different times but were already coexisting in many populations as early as 1992 (Shrimpton and Rokx 2012: 1–8). This observation contributed in part, to the coining of the term, ‘Double Burden of Malnutrition’, (DBM).

DBM was initially described simply as ‘undernutrition, including micronutrient deficiencies, coexisting with overnutrition: obesity and overweight’ (Shrimpton and Rokx 2012: 1). This definition has since been expanded and DBM is now described as the coexistence of undernutrition along with overnutrition – obesity and overweight, or diet-related NCDs, within individuals, households, and populations, and across the life course (WHO 2017a). Diet-related NCDs typically occur as a direct consequence of obesity and overweight, but also do occur independently of an individual’s obesity or overweight status. DBM is a global issue of public health concern, but even more so for low-income countries which are experiencing rapid social, demographic and economic change (Shrimpton and Rokx 2012: 8).

1.2 Obesity and Non-communicable Diseases (NCDs)

Obesity and overweight have continually emerged as major risk factors for several NCDs, including diabetes and cardiovascular diseases, due to their adverse metabolic effects on blood sugar, blood pressure and blood lipids – metabolic syndrome; as well as for other chronic diseases such as musculoskeletal diseases and various cancers (WHO 2002: 9, 60). Obesity and overweight are thus synonymously described as representative of ‘excessive fat accumulation in the body, which may impair health’ (WHO 2017b).

It has been recognised, for a long while now, that as a person’s BMI increases beyond 25kg/m², each 5-unit increase corresponds to a 29% increase in the risk of mortality (MacMahon et al. 2009: 1087). In addition, obesity and overweight have been identified as being among the leading risk factors for mortality worldwide (WHO 2009; GBD 2015 2015: 1674). Raised blood pressure is the number one metabolic risk factor of obesity and overweight. It is attributable to as many as 19% of annual deaths globally (WHO 2017c).

This trend also encompasses several low-income countries, including countries in sub-Saharan Africa. In Uganda, several studies have found that obesity and overweight are significantly associated with metabolic risk factors, especially raised blood pressure among adults, with the highest odds occurring at obese BMI. Furthermore, a national-level study based on self-reported measures of NCDs found a disproportionately higher burden in women than in men. (Guwatudde et al. 2015: 8).

However, it is important to note that not all people with obesity – even long-term morbid obesity experience metabolic syndrome or an increased risk of metabolic syndrome (Hinnouho et al. 2013: 2297). This phenomenon was first identified over 22 years ago now and has been described as metabolically healthy obesity (MHO) (Sims et al. 2001: 1501), with the opposite of this being metabolically unhealthy obesity (MUO).

Approximately 5–50% of individuals classified as obese are also classified as metabolically healthy, depending on the criteria that are used for classification. The range is big because the criteria for identification still vary significantly from place to place and from study to study (Roberson et al. 2014: 7; Wildman et al. 2008: 1620; Pajunen et al. 2011: 5; Shea et al. 2011: 626; Smith at al. 2019: 3980). Moreover, the MHO phenomenon is more commonly observed in women than in men (Van Vliet-Ostaptchouk et al. 2014: 5).

There is little consensus in literature about what circumstances constitute a classification of an otherwise obese individual as being metabolically healthy (Blüher 2010: 40). The most common definition of MHO is that it is the existence of obesity (BMI≥ 30kg/m²) without the coexistence of metabolic disease (Sims et al. 2001: 1501; Karelis 2008; Blüher 2010: 40).

The underlying factors for MHO are also less understood but it has been hypothesised that MHO may be defined as a group of obese individuals with predominantly subcutaneous fat deposits and with little or no visceral and intrahepatic fat (Muñoz-Garach et al. 2016: 4). Nevertheless, lifestyle and physical activity have been indicated as major predictors of whether an obese individual is classified as having MHO or MUO (Bobbioni-Harsch et al. 2012: 2066; Ortega et al. 2013: 393; Katzmarzyk et al. 2005: 393). The evidence on MHO as a transient state is largely inconclusive but having MHO appears to be a life-long state in some people (Muñoz-Garach et al. 2016).

Lastly, most studies do not report about the actual prevalence of metabolic syndrome within obese populations in their study, unless that study set out to examine the issue of MHO in the population. Therefore, it is difficult to establish the prevalence of MHO particularly in areas with a porosity of research data on obesity such as sub-Saharan Africa.

One such study was conducted in an HIV-infected South African population. In this population, the total proportion of adults including males and females who were classified as obese based on BMI was 33.7% (N=252). However, more than half of the obese individuals (55.2%) were classified as having MHO. This points to the possibility of a high prevalence of MHO within this African sub-population (Nguyen et al. 2016: 5–6).

If it is indeed the case that there are some populations within which the prevalence of MHO is high – where many people with obesity are healthy, this would theoretically factor into how people interpret body size, how people manage body size and, paradoxically, into the prevalence of obesity within the specific population.

1.3 Obesity and Overweight in Women

The DBM has increased in most countries around the world, but more so in the poorest low-and middle-income countries (LMICs). This is mainly due to obesity and overweight increases alongside long-standing undernutrition. This is evident in various countries in Asia and in sub-Saharan Africa. Understanding the drivers of obesity in these regions is instrumental in understanding the factors behind the DBM phenomenon (Popkin et al. 2020: 5). Dramatic increases in rates of obesity and overweight have been reported all over the world, particularly among women (Stevens et al. 2012: 4–7). The prevalence of female obesity was reportedly greater than that of men in most places, particularly in sub-Saharan Africa (Finucane et al. 2011: 563).

The global health repository of the WHO shows persuading evidence of the increasing trend of obesity and overweight globally, and across income regions. As of 2016, the combined global prevalence of obesity and overweight was highest in the Americas at 62.5%, followed by Europe at 58.7%, the Eastern Mediterranean at 49.0%, the Western Pacific at 31.7% and Africa at 31.1%. The lowest prevalence was in Southeast Asia at 21.9%.

Over the 30-year period between 1986 and 2016, the global obesity prevalence alone increased 2.1 times rising from 6.1% in 1986 to 13.1% in 2016. In 1986, the global ratio of the prevalence of obesity among females to males was 1.9. In 2016, it was 1.4 (WHO 2017d).

Although the disparity is reducing, the prevalence of obesity has always been higher in women. Furthermore, although the prevalence of obesity has been highest in high-income countries, more significant increases have been reported in low-income countries. The ratio of obesity prevalence in females to males is particularly higher in the low-income regions.

In high-income countries, the total obesity prevalence increased 2.1 times, rising from 11.6% to 24.6%. The ratio of the prevalence of obesity among females to males in high-income countries went from 1.3 to 1.0. In low-income countries, the total obesity rose 4.0 times increasing from 1.7% to 6.8%. The ratio of the prevalence of obesity among females to males in low-income countries went from 4.3 to 2.7 (WHO 2017e).

Overall, 154 out of 191 countries (80.6%) have a higher proportion of obese women than men. But it’s worth noting that there are up to 22 countries (11.5%) with equal proportions of obese women and men, and even 15 countries (7.9%) with a higher proportion of obese men than women. These include countries such as Switzerland, Denmark, Japan and Sweden (WHO 2017f) (Table 1.1).

Table 1.1. Countries with the lowest ratio of obesity in women

Data Source: WHO (2017f), Table created by the author.

In Africa, the prevalence of obesity increased 3.3 times, rising from 3.2% in 1986 to 10.6% in 2016. The ratio of the prevalence of obesity among females to males in Africa went from 4.7 to 2.7 (WHO 2017d). Notably, there is a disproportionately higher burden of obesity in urban areas (Agyemang et al. 2015).

All African countries have a higher proportion of obese women than men and the countries with the highest proportion of obesity among women compared to men are found in Africa. Uganda is one of the top five countries with the highest ratio of obese women to men – 4.8, (WHO 2017f) (Table 1.2).

Table 1.2. Countries with the highest ratio of obesity in women

Data Source: WHO (2017f), Table created by the author.

In these countries, the situation is particularly complicated by the slow progress in reducing undernutrition (FAO 2006). The number of undernourished people globally dropped substantially by 2004–06, but since then there hasn’t been much change. In fact, in sub-Saharan Africa absolute numbers have steadily increased (FAO 2012: 7). Progress in reducing the prevalence of stunting and wasting in children has been insufficient, and Africa has experienced the smallest decrease (UNICEF, WHO and WB 2021). Increases in adult obesity and overweight alongside slow progress in reducing undernourishment and childhood undernutrition have contributed to the existence of the DBM (FAO 2006; WHO 2017c).

The DBM phenomenon profoundly complicates nutritional interventions, because overnutrition and undernutrition have so far been understood and treated as distinct problems with different causative pathways (Jehn and Brewis 2009).

In fact, historically the menu of programmes to address nutrition problems in developing countries has focused on reducing undernutrition (FAO 2006) and the possibility of undernutrition and overnutrition – obesity, overweight and diet related NCDs coexisting is not usually considered in the design of nutrition interventions (Doak et al. 2005).

Most studies on DBM and, indeed, on obesity have been conducted in some of the biggest countries around the world including India (Vanderkloet 2008), China (Doak et al. 2000, 2002), Brazil (Doak et al. 2000), Indonesia (Roemling and Qaim 2013). This in addition to some countries in Central and South America such as Argentina (Basset et al. 2014), as well as some in Asia including Malaysia (Khor and Sharif 2003) and the Philippines (Angeles-Agdeppa et al. 2003). However, there are almost no studies in African countries besides Barnett et al. (2011) and Ntandou and Delisle (2005). This is a big oversight considering the rapidly increasing prevalence of obesity and diet-related NCDs alongside widespread hunger and child undernutrition in Africa.

1.4 Causes of the Double Burden of Malnutrition and Obesity

Studies on DBM have attempted to establish the predictors of the phenomenon through the life course, at the national, population level, and at the household level. Often, households have been categorised according to the nutrition status of at least two people; usually mother–child pairs into several categories such as overweight mother–stunted child, overweight mother–overweight child, overweight mother–normal child, among others. Based on these categorisations, researchers have attempted to identify the characteristics that distinguish DBM households from other households as a way of determining the predictors of DBM.

Jehn and Brewis (2009) proposed that the DBM may not be a unique condition with distinct nutritional aetiology but one that is a consequence of rapid increases in maternal overweight, because they found DBM households to have similar characteristics to overweight households. However, Doak et al. (2005) reported that, whereas the DBM household could not be easily distinguished from overweight households in some countries, DBM households could not be distinguished from underweight households in other countries.

On the other hand, Ntandou et al. (2005) who did a community-based survey in Benin reported that DBM households could not be distinguished from underweight households but showed clear contrast from the overweight only households. The question of why the DBM happens within the same household thus remains largely unanswered. The only consensus so far is that DBM households are malnourished households.

The 1990 and more recently, the 2020 UNICEF conceptual framework is useful for assessing the causes of malnutrition in women and children. It categorises the causes of malnutrition into the immediate, underlying and basic causes that operate at the individual, household and societal levels, respectively. At the individual level, diet and disease are shown to interact to cause malnutrition. At the household level, access to food, maternal and childcare practices, water, sanitation and health services are seen as risk factors. At the society level, the quantity and quality of resources both human, economic and organisational and how they are controlled are shown as contributing factors. Underlying these, are all potential resources including environment, technology and people (UNICEF