The rapid increase of overweight and obesity rates in South Africa : a study on the determinants and the socioeconomic causes for obesity

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The rapid increase of overweight and obesity rates in South Africa

A study on the determinants and the socioeconomic causes for obesity

Naam: Tiffany Groot - Studentnummer: 11019026 - Docent: Niels Beerepoot – 2e_{lezer: Patrick Weir} – Opleiding: Sociale Geografie – E-mail: tn.groot@hotmail.com - Datum: 18 juni 2018

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1. Introduction

Millions of people think of the stereotype of malnutrition and emaciated children when they think of Africa. However, this image is far from the truth. Numerous African countries, especially in Sub Saharan Africa, are facing a new problem: shocking increases in people suffering from obesity. This problem has been occurring over the past 25 years and is most visible in urban areas (The South African, 2018). The African continent is going through rapid urbanization processes which go hand in hand with lifestyle changes such as a decrease in physical activity and natural and raw foods being replaced by processed and fast foods (Nilson, 2018). A decrease in physical activity and unhealthy changes in diet are closely associated with obesity and chronic, obesity related diseases such as type-2 diabetes and coronary heart diseases (The South African, 2018). This phenomenon is becoming a serious public health issue since African doctors now have to deal with both sides of the coin, such as diseases which come forth from undernutrition as well as diseases related to obesity (World Health Organization, 2018). Besides lifestyle changes which contribute to the development of obesity, there is also a stigma around being thin among black communities. Being thin is associated with being poor as weight gain is being viewed as a sign of prosperity (Allison, 2015). This creates the assumption that being overweight is actually something to strive towards.

Multiple researches present a nutrition transition in developing countries whereby a shift is visible from traditional foods which are high in nutritional value towards western diets low in nutritional value, containing manufactured and fast foods, high in sugar and fats (Popkin & Gordon-Larsen, 2004; Malik et al., 2013; Popkin, 2006). This nutritional shift is often accompanied by a reduction in physical activity (Malik et al., 2013). This leads to an increase in input in the energy balance and a decrease in output, which causes weight gain and a greater risk for overweight and obesity (Sobal & Stunkard, 1989). These changes in lifestyle which promote overweight and obesity are argued to be facilitated by socioeconomic factors as globalization, economic growth and urbanization, which are important themes within the discipline of human geography (Popkin & Gordon-Larsen, 2004; Malik et al., 2013; Monteiro et al., 2004). Although these concepts are very common among human geographers, most research on this topic has been performed by researchers from a public health background. Therefore, it is important for human geographers, experts in how social issues are distributed over space, to join this debate.

South Africa is taken as a case study for this thesis project, as it is the most developed African country and is leading the trend of high obesity rates as the most recent South Africa Demographic and Health Survey of 2016 reports that 68% of women and 31% of men are either overweight or obese (SADHS, 2016). This thesis project focuses on the socioeconomic causes of the high rates of obesity in South Africa as well as on the people who are most likely to develop obesity. It analyzes to what extent globalization, economic growth, urbanization and cultural perceptions enhance lifestyle changes which promote a lifestyle associated with overweight and obesity and how this influences the high obesity rates

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4 in South Africa. Furthermore, it attempts to find an explanation for these significant differences in obesity rates between South African men and women as well as identifying other characteristics of people who are most likely to develop obesity.

The thesis project is sectioned in the following way. Firstly, a theoretical framework is framed. This describes the main concepts used and the theories that are tested throughout the research project. These theories are based on research on obesity in developing countries as a whole, which are tested by analyzing the theories on obesity in South Africa specifically. Then, the research question and the sub questions are framed which will be answered through this thesis project. Additionally, the methodology which is used to obtain data is explained, which is followed up by two chapters on obesity in South Africa. The first chapter describes how obesity exists in South Africa, the current numbers and trends of obesity as well as the characteristics of the people who are likely to develop obesity. On top of that, it gives insight in how black South Africans think of the obesity problem and if it is actually perceived as a problem among the African communities. The following chapter goes into the socioeconomic causes of obesity in South Africa by focusing on globalization, economic growth, urbanization and cultural perceptions. The thesis project is finalized with a conclusion which gives an answer to the research questions and its supporting sub questions and which either confirms or denies the theories from the theoretical framework.

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2. Theoretical Framework

Obesity is rapidly increasing worldwide (World Health Organization, 2018). However, it seems that obesity is not solely a problem in high income countries anymore, as the fastest increase happens in middle and lower income countries (Malik et al., 2013; World Health Organization, 2018). This shift of obesity burden tends to be more often a problem for the poor, since obesity tends to shift towards people with a lower socioeconomic status, SES, on a worldwide basis (Popkin & Gordon-Larsen, 2004; Malik et al., 2013; Monteiro et al., 2004). This rapid increase of obesity and the shift of obesity burden are being generated by many socioeconomic causes, including globalization, urbanization, economic growth and cultural perceptions of beauty, which enhance lifestyle changes which could directly impact the risk for obesity (Malik et al., 2013). These lifestyle changes could be split up into two aspects, diet and physical activity, both impact the energy balance, which when being positive could cause overweight or obesity (Sobal & Stunkard, 1989). The rapid growth of overweight and obesity in South Africa, a middle-income country, will be analyzed by the use of the following concepts: obesity and overweight, globalization, urbanization, economic growth and cultural perceptions. Firstly, these concepts are explained and the main theories around the concepts in relation to overweight and obesity are framed. Additionally, the concepts are operationalized to transform these into measurable variables, which is important when operating research. Furthermore, a conceptual model is added at the end of the chapter to emphasize the relationships between the concepts.

2.1 Obesity and overweight

Overweight and obesity could be defined as the excessive fat accumulation which could damage a person’s health (World Health Organization, 2018). The fundamental cause of overweight and obesity is an energy imbalance consisting of consumed and expended calories (World Health Organization, 2018). There are two global trends which promote a positive energy balance, an increase in intake of energy-dense, high in fat foods as well as a decrease in physical activity due to a shift towards sedentary lifestyles (Malik et al., 2013; World Health Organization, 2018). Overweight and obesity have to be taken seriously as it could be linked to more deaths worldwide than underweight (World Health Organization, 2018). The risk for noncommunicable diseases, such as cardiovascular diseases, diabetes and many cancers increases with an increase in BMI (Popkin, 2006; World Health Organization, 2018). These serious chronic conditions can reduce the quality of life as well as increase the risk of premature death (World Health Organization, 2018). In 2000, 36504 deaths attributed to excess body weight have been reported in South Africa, existing of 7% of all deaths that year (Igumbor, et al., 2012). Furthermore, in 2004 non-communicable diseases linked to dietary intake together with respiratory diseases contributed to 12% of the South African disease burden (Igumbor et al., 2012). Thus along with rapidly

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6 rising overweight and obesity rates is the rise of noncommunicable diseases, which carries a serious health concern.

This thesis project uses two dimensions of obesity, namely overweight, the stage before obesity, and obesity itself. Both obesity and overweight could be measured through a body mass index (BMI) which measures a person’s weight in kilograms divided by the square of a person’s height in meters (World Health Organization, 2018). Overweight contains a BMI greater or equal to 25 and obesity contains a BMI greater or equal to 30. Within this research two indicators are used for overweight and obesity, namely average BMI, which could indicate whether a person is overweight or obese and obesity prevalence which indicates the commonness of obesity within specific population groups.

2.2 Globalization

One of the contributing factors to obesity is globalization and the changes that it brings forward in terms of diet and lifestyle patterns. Globalization through shifts in technological innovation, globalized modern food processing, marketing and distribution techniques and mass media has had a profound effect on diet and physical activity patterns which promote a positive energy balance, and which eventually could cause overweight or obesity (Popkin, 2006). Changes due to the above named factors of globalization are particularly taking place in low and middle income countries (Popkin, 2006).

Global market expansion and the promotion of freer movements of goods, has had an immediate effect on food availability and lifestyle habits, as it altered the food supply through the expansion of fast food chains and multinational food organizations (Popkin, 2006; Malik et al., 2013). Two shifts with regard to the food supply in developing countries are visible which create more food availability and food options. Firstly, international food companies like McDonald’s and Coca-Cola are rapidly spreading, which offer high calorie foods, large portions, high amounts of processed meats, sugary beverages, unhealthy fats and sugars (Popkin, 2006; Malik et al., 2013). These international fast food chains are quickly followed up by local food chains which follow the models of international food companies, serving the same type of dishes (Popkin, 2006). Secondly, large supermarket chains have gained control over food distribution (Popkin, 2006). Fresh markets, which used to be a major source of food supply are being replaced by multinational, regional and local supermarkets, which are large providers of processed higher-fat, added-sugar, and salt-laden foods and are hereby replacing fresh healthy foods with unhealthy options (Popkin, 2006; Malik et al., 2013). On top of that, food costs are declining because of the movement towards mass food production, accommodated by globalization, which contains often ready to eat high fat foods (Popkin & Doak, 1998). These changes have led to a nutrition transition, which shows a shift towards Western diets, which are high in saturated fats, sugar, refined foods, low in fiber and which are associated with lower levels of physical activity (Popkin & Gordon-Larsen, 2004). Popkin & Gordon-Larsen (2004) describe three stages of the nutrition transition. A stage of famine which recedes with a rise of income, a stage in which diet and physical activity change

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7 and new disease problems and increased disability emerge and a stage of behavioral change which reverse these negative tendencies. The nutrition transition is further driven by urbanization, economic growth and culture, which thus act as moderators for how globalization influences the nutrition transition (Popkin & Gordon-Larsen, 2004).

The nutrition transition, which shows a shift towards unhealthy western diets, combined with a reduction in physical activity leads to greater risks for obesity. Globalization has influenced physical activity patterns through the spread of mass media which promote sedentary lifestyles, leading to a decline in physical activity during leisure (Popkin & Gordon-Larsen, 2004). There has been a profound increase in the ownership of television within developing countries, which further supports a sedentary lifestyle and physical inactivity (Popkin, 2006).

These changes in diet and physical activity which are accompanied by globalization through changes in the global food production and distribution system, the use of mass media and technical advancements are further moderated by increases in GNP and SES and urbanization, which will be explained in the next paragraphs (Malik et al., 2013).

In this thesis project the focus is on one dimension of globalization, the expansion of the global food market. This dimension is measured by the spread of fast food chains and supermarket chains over South Africa. The expansion of a global food market is analyzed since the shift towards a western diet, which is made possible by the expansion of the global food market, seems to be one of the root causes for the high increases in obesity and overweight.

2.3 Economic growth

Economic growth, on a macrolevel in GNP and on a microlevel in socioeconomic status (SES), could be seen as a moderator for the extent to which globalization alters patterns in diet and physical activity. As stated above, the increase in obesity happens at a faster rate in lower- and middle income countries than in high income countries (World Health Organization, 2018; Monteiro et al., 2004; Malik et al., 2013). There is a positive relation between the increase in obesity and economic growth in low and middle income countries, since these countries undergo the nutrition transition and lifestyle changes without undergoing growth in health services and education (Malik et al., 2013).

However, SES seems to be a moderator for how economic growth influences the likelihood of obesity. When GNP increases people from lower SES tend be more vulnerable for developing obesity (Monteiro et al., 2004). This means that when a country experiences economic growth the burden of obesity is shifting towards people from a lower SES. Therefore, obesity prevalence depends on in which income category a country finds itself in. Belonging to a low SES could lead to a lower risk for obesity in low income countries, can both reduce and increase the risk of obesity in lower middle income countries and is a systematic risk factor for obesity in upper middle income countries (Popkin & Gordon-Larsen, 2004). This would mean that in an upper middle income country like South Africa the majority of the obesity burden would lie on people belonging to a lower SES. Thus, SES is a significant moderator

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8 of the effect of a country’s level of economic development on obesity.

Besides SES, urbanization could be seen as a moderating factor for the effect of a countries’ economic development on obesity. The likelihood for people with low incomes to develop obesity is namely higher in highly urbanized low and middle income countries than the likelihood for their wealthy counterparts (Malik et al., 2013). This is due to a widespread access to affordable food high in energy and fat and low in nutritional value in urban areas (Malik et al., 2013). People belonging to a higher SES are less at risk for obesity, which could be due to higher levels of health education, time for leisure, sufficient income for healthy foods and access to health care (Malik et al., 2013; Monteiro et al., 2004).

This thesis project mainly focuses on economic growth on a microlevel, SES, considering it unlikely that small fluctuations in GNP will have a big effect on South Africa’s obesity prevalence. Within this thesis South Africa is considered as a middle income country, which represents South Africa’s level of economic development. The theories explained above are therefore applied to a middle income country. Furthermore, SES is measured by focusing on a person’s wealth and level of education. SES is also used to analyze the characteristics of people who are most likely to develop obesity.

2.4 Urbanization

Research has shown that obesity is most visible in urban areas (Popkin, 1999; Malik et al., 2013). Urbanization is often linked to economic growth, modernization and globalization. Therefore, it is most likely that the factors of globalization and economic growth which contribute to the prevalence of obesity correlate with urban aspects. The prevalence of obesity in urban areas is due to a number of different aspects of urban residency, such as changes in built in living environment, a broad range of food options available and lifestyle changes related to technological advancement and mechanization (Malik et al., 2013). These are all aspects which go hand in hand with globalization and economic growth and therefore cannot be seen separate from one another.

These changes due to urban residency create sedentary lifestyles for people which go hand in hand with changes in diet and energy expenditure leading to a positive energy balance (Malik et al., 2013). Besides, urbanization leads to a shift in occupational sector from high-energy expenditure jobs towards the service sector, leading to a reduction in physical activity at the workforce (Popkin, 1999; Popkin & Gordon-Larsen, 2004). On top of that, there is also a noticeable shift in modes of transportation. Changes to the built in environment, such as the construction of roads and high ways have limited the opportunity for walking or cycling and has led to a shift towards motorized transportation, causing a decline in physical activity (Malik et al., 2013). Likewise, urbanization has led to a decline in physical activity in leisure due to densely populated areas with little outdoor recreational space (Malik et al., 2013; Popkin & Gordon-Larsen, 2004). The occupational shift towards the service sector goes hand in hand with sedentary leisure activities, such as watching tv, and mechanization of household chores (Malik et al., 2013). Thus, urbanization facilitates modernization and technical

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9 advancements which promote physical inactivity during leisure, transportation and within occupation, which in its turn reduces the output of people’s energy balance, which could be directly linked to overweight or obesity.

Besides changes in physical activity, urbanization causes changes in diet patterns. Urban people’s diets distinct differently from the diet of rural people (Popkin, 1999). As mentioned above, globalization has led to an increase in food supply with the spread of international fast food and supermarket chains, which is fundamental to the nutrition transition that developing countries face. This nutrition transition is facilitated by urbanization, as international market penetration most often occurs in urban areas (Popkin, 1999). The nutrition transition is further fueled by a reduction in prices of low quality and energy dense foods and economic growth which enhances the purchasing power (Malik et al., 2013). Urban people’s diet contain overall more sugar, more animal source products, more refined grains instead of whole grains, are higher in fat and exist of more food prepared away from home and more processed foods (Popkin, 1999; Malik et al., 2013; Popkin & Doak, 1998). However, not all urban people’s diets are the same. Economic growth acts as a moderator for how urbanization influences people’s diet patterns. So will the consumption of caloric sweetener increase as GNP and urbanization increase (Popkin & Gordon-Larsen, 2004). Although, in less urbanized countries this increase is especially visible with an increase in income, while in more urbanized countries this increase is rather visible within low incomes than in high incomes (Popkin & Gordon-Larsen, 2004). An increase in the consumption of animal source foods is especially high among urban residents and higher among high incomes than among lower incomes (Popkin & Gordon-Larsen, 2004). The increase in consumption of low in nutritional value foods leads to more less-valued input in the energy balance, which along with declines in physical activity, accommodated by urbanization and modernization, leads to a positive energy balance resulting in overweight and obesity.

One dimension of urbanization is analyzed in this project, namely urban residency. Within the dimension of urban residency the prevalence of obesity among urban and rural residents is compared. Different aspects of urban residency are analyzed, such as the living environment and the presence of fast food and supermarket chains.

2.5 Cultural perceptions

Besides socioeconomic factors as globalization, economic growth and urbanization, there is also a sociocultural factor which could contribute to the rapid increases of obesity, namely cultural perceptions on beauty and body size. Many developing countries know a history of famines or are still experiencing high numbers of undernutrition. Fat is therefore seen as high valued (Sobal & Stunkard, 1989). Because of its history of famines and undernutrition many parts of Sub Saharan Africa consider overweight and obesity as a sign of success, good health, happiness and prosperity (Renzaho, 2004). Likewise, Sub Saharan Africa has been exposed to chronic poverty, population displacement because of war, ethnic conflicts, natural disasters and high levels of malnutrition (Renzaho, 2004). This cultural exposure to

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10 suffering could have major influences on the social construction around body weight and Sub Saharan Africa’s preference for big body sizes (Renzaho, 2004). Thus, a region’s history around food security and poverty can have a major impact on how body size is socially constructed. On top of that, socialization is a factor which contributes to the ideal of a big body size, especially among black women (Micklesfield et al., 2013). For example, young black girls are taught that being big is something to strive for by encouraging weight gain prior to marriage which indicates fertility and the ability to bear children (Micklesfield et al., 2013). Additionally, after marriage a woman is encouraged to gain more weight as it reflects the husband’s ability to take care of her (Puoane et al., 2002; Micklesfield et al., 2013). Furthermore, cultural perceptions act as barriers for physical activity as well, since physical activity is associated with weight loss which is un-preferable (Micklesfield et al., 2013). Besides, with the massive increase in prevalence of AIDS among black South Africans, being overweight is seen as a sign of good health, while thinner people are stigmatized for carrying diseases (Puoane, et al., 2002; Micklesfield et al., 2013). Another cultural factor which is in favor of a bigger body size among black women and which promotes behavior associated with obesity is the fact that the mother of the household is expected to be an authoritative figure, combined with the expectation among black communities that people in positions of power should be big (Micklesfield et al., 2013). These factors result in a high preference among black communities for a bigger body size and stigmatize physical activity and weight loss. Thus, historical societal traumas related to food security as famines, undernutrition and wars have had a direct result in how body sizes are culturally perceived and in its turn influence people’s behavior by promoting lifestyles which are associated with overweight and obesity.

The concept of cultural perceptions could be divided into two dimensions: ideal body size and societal concerns around obesity. A larger body size is preferred in African communities, especially among women, since it has many positive connotations. A larger body size goes along with an increase in BMI which leads to a greater risk for overweight and obesity. Furthermore, when a large body size is actually perceived as something positive within society the negative outcomes of it, such as non-communicable diseases, could not be seen as a concern. It is therefore important to measure to what extent overweight and obesity are seen as a societal concern among black South Africans.

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11 2.6 Conceptual model

The concepts and theories explained in this chapter are presented in the following conceptual model.

Globalization, economic growth and urbanization have an influence on diet and physical activity patterns which in many developing countries leads to a positive energy balance, causing overweight and obesity. Additionally, these factors influence each other and can enhance the effect on lifestyle changes. For example, globalization with its spread of fast food chains is accommodated by urbanization, as fast food restaurants are most often situated in urban settings. Furthermore, SES moderates the effect of economic growth and urbanization; as a country’s economic development or urbanization level grows the prevalence of obesity shifts towards people from a lower SES. Besides globalization, economic growth and urbanization, cultural perceptions influence the prevalence of obesity, since a big body size is most preferable in developing countries. This creates a set of cultural habits which causes people to change their lifestyle habits in order to gain weight. Reaching a level of overweight or obesity could be very problematic as it increases the risk for non-communicable diseases, such as diabetes, cardiovascular diseases and different types of cancer.

Economic

development Urbanization Globalization Cultural perceptions

Socioeconomic status

Lifestyle changes

Overweight and obesity

Risk for non-communicable

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3. Research questions and research methods

This chapter discusses the research questions on which this thesis is based and which will be answered through the research performed in this project. The theories described in the previous chapter form a basis for the research questions. Subsequently, the second section of this chapter describes the methods used for the data collection and research.

3.1 Research questions

This thesis project focuses on the causes of the high rates of obesity in South Africa as well as on the people who are most likely to develop obesity. Therefore the main research question holds both elements and will be as following: What are the determinants and socioeconomic causes for the high obesity rates in South Africa?

This research question is broken up into smaller sub-questions to provide more direction for the research. The first sub-question will be: What are the socioeconomic trends which cause obesity in South Africa? This question focuses on how the concepts globalization, economic growth and urbanization influence the likelihood to develop obesity.

The second sub-question focuses on the element of determinants of the main question, which identifies the people who are most at risk for developing obesity. What are the social characteristics of the people who are most vulnerable for developing obesity? Hereby social characteristics as SES, gender and race are analyzed to study which population groups are most vulnerable for obesity.

The third research question is: How is obesity and overweight perceived among black South African communities? This question is centered around the cultural perceptions around body size and obesity, specifically among black communities, as is proven that communities who have been historically deprived in food security show more positive values towards bigger body sizes. This question thus focuses on whether the black community shows a preference towards bigger body sizes and whether overweight and obesity are seen as a concern within these communities.

3.2 Methodology

This thesis project has an explanatory nature as it is mostly based on existing literature on the determinants of obesity as well as on the socioeconomic causes for obesity. Much research has been performed on these topics, however most research is performed from a public health background. Topics as globalization, urbanization, economic growth, race and gender are very familiar among human geographers. Therefore, this thesis project can offer new perspectives on these topics’ relation to obesity by reviewing these researches. Thus, the most used method to collect data will be literature study. The literature study is conducted by collecting as much research on each topic on South Africa as possible

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13 and by comparing the studies’ main theories on that specific topic in relation to obesity in South Africa. If the studies propose similar theories, these theories can be confirmed. On top of that, this literature study links different theories on the different concepts with each other in order to explain how the concepts enhance each other in influencing obesity prevalence. Besides literature study, this research project uses statistics on the social characteristics of people to determine who is most vulnerable for obesity. These statistics are also used to understand the effects of urbanization and economic growth and to complement the literature study on these concepts’ relation to obesity.

Statistics are mainly used in chapter four “Obesity in South Africa” which describes how obesity is visible in South Africa, the people who are most likely to develop obesity and how obesity is perceived among black South Africans. The data on which this chapter is based is obtained by the use of the South African Demographic and Health Surveys of 1998 and 2016. The South African Demographic and Health Survey, SADHS, is a nation-wide survey conducted by Statistics South Africa, the National Department of Health and the South African Medical Research Council (SADHS, 1998; Stats SA, 2016). The SADHS presents data on the health and disease patterns of South Africa, whereunder data on obesity prevalence among South African adults, and contains information of a sample of 15000 households throughout nine provinces, making it a nationally representative survey (SADHS, 1998). As the SADHS of 1998 has been the first national survey on demographics and health and the SADHS of 2016 has been the latest version, the information of both surveys is used to discover the trends around obesity prevalence and BMI. To discover the trends around the prevalence of obesity and the determinants of obesity descriptive statistics in the form of graphs are analyzed, which are constructed through excel. Four social categories from the SADHSs have been selected for this research project, namely gender, residence, level of education and race. The category of gender has been selected as there is a remarkable difference in obesity prevalence among men and women. The social category of residence focuses on how the average BMI and obesity prevalence differs among urban and non-urban residents, as research has shown that urbanization could influence obesity prevalence. Furthermore, level of education is an indicator of SES, which represents economic growth on a microlevel, and is interesting to analyze in relation to obesity as it is stated in the theoretical framework that more increasingly obesity is shifting towards people from a lower SES. Race is taken as a social category, to examine how black South Africans who are associated with positive beliefs towards obesity, differ from other population groups. The indicator of average BMI is adopted from the SADHS and the indicator of obesity prevalence is the percentage of overweight or obese, which is adopted from the SADHS as well. Besides presenting how obesity is visible in South Arica by focusing on average BMI and obesity prevalence, chapter four also discusses the cultural perceptions towards overweight and obesity among black communities. The data used to discuss these cultural perceptions is obtained from a literature study, which gathered researches on cultural perceptions towards obesity among black South African communities and compared main theories generated from these researches in order to conduct my own argument. The theories gathered

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14 from this literature study are compared with the theories from the theoretical framework. When the researches from the literature study use the same theories as the theoretical framework the theories from the theoretical framework can be confirmed.

Chapter five focuses on the socioeconomic causes for obesity, globalization, economic growth and urbanization, and analyzes to what extent these concepts influence the obesity epidemic in South Africa. The data for this chapter is mainly obtained from a literature study. The same method is used as in chapter four on the cultural perceptions. First theories are gathered from former researches on these topics, where my own argument is based on and then these theories are compared with the theories from the theoretical framework. The theories from the theoretical framework on globalization, economic growth and urbanization are based on developing countries as a whole. The literature study is based on how globalization, economic growth and urbanization influence the obesity prevalence in South Africa. This chapter thus either confirms or rejects the theories on developing countries by analyzing the theories on South Africa. Besides the literature study, the section of economic growth also makes use of statistics gathered from the SADHS of 2016 on obesity prevalence per wealth quintile of the population and further builds on the findings of chapter four on education and obesity prevalence. This data helps to analyze the relationship between SES and obesity.

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4. Obesity in South Africa

This chapter looks into how obesity is visible in South Africa, how obesity trends have evolved over time and how obesity is perceived among black communities. Firstly, this chapter describes how the prevalence of obesity and the average BMI have changed between 1998 and 2016. It does so by analyzing the average BMI per social category by sex and year of the survey. Furthermore, the percentage of overweight or obese people per social category by year of survey is analyzed separately among men and women. Secondly, a closer look is given on the differences in obesity prevalence between men and women per social category in 2016, as women tend to have a higher obesity prevalence (SADHS, 2016). Therefore, there is focused on how obesity prevalence is distributed over the social categories and how this differs among men and women. Furthermore, this chapter goes into the cultural perceptions of black South Africans towards body size and obesity. It analyzes whether black South African communities actually perceive obesity as a problem and it studies how cultural perceptions enhance lifestyle changes associated with obesity. Finally, this chapter ends with some concluding remarks on how obesity is visible in South Africa both in terms of how average BMI and obesity prevalence are distributed over different social categories and in terms of the cultural values towards obesity.

4.1 The evolvement of obesity between 1998 and 2016

Since the first national survey was conducted in 1998 the average BMI, especially among women, has increased as data from the SADHS of 1998 and 2016 shows. Figure 1 presents how the average BMI per social category and gender differs between 1998 and 2016. It shows that among most social categories women tend to have a higher BMI than men, which during the period of 1998 to 2016 increases even further. In every social category women have an average BMI above 25 in 2016, which means that in all these categories women tend to be overweight. In the categories of residence and education the average BMI among men stays quite stable between 1998 and 2016, with the exception of higher education. The average BMI of higher educated men has increased, leading to an average BMI of over 25 in 2016. It is evident that higher education considerably deviates from the other dimensions of education. Especially men show a higher average BMI when having enjoyed higher education compared to lower educated men. Within the social category of residence the graph shows a similar trend in urban residence as well as in non-urban residence. The average BMI of men in 1998 stayed almost the same in 2016 and shows a slight difference in urban residence and non-urban residence. The trends in BMI among men and women between 1998 and 2016 between urban and non-urban residence differ not as much as expected. As explained in the theoretical framework, different aspects of urban residency such as greater food availability and technological advancements which often create sedentary lifestyles lead to changes in diet and energy expenditure causing a positive energy balance, which creates

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16 a higher risk for overweight or obesity. However, these effects are not exactly visible in the average BMI in urban and non-urban residences as both dimensions show similar trends. The following chapter will go more into the effects of urbanization on obesity prevalence and the possible explanations as to why urban and non-urban residency are that similar in average BMI. Furthermore, within the social category of race among men especially white men tend to have the highest BMI. As for women, black women tend to have the highest BMI in 1998, while in 2016 colored women are closest to being obese. On top of that, the average BMI of Asian women remarkably increased during the period of 1998 to 2016, with an increase in BMI from 25.1 to 29.7 (SADHS, 1998; SADHS 2016). All in all, women tend to have higher BMIs than men in almost every social category and experience the biggest increase in BMI in most categories, while among men two social categories stand out: the higher educated and white men.

Figure 1: Average BMI among social category between 1998 and 2016

Figure 2 shows the percentage of overweight or obese men, thus men who have a BMI higher than 25, per social category in 1998 and 2016. The social categories with the highest percentage of overweight or obese men are the higher educated men and white men. This was also indicated in figure 1, as higher educated men and white men tended to have the highest BMI among the different social categories. Besides these categories having the highest percentage of overweight or obesity, these categories experience the largest increase in overweight and obesity as well. Figure 2 shows that the category of higher education increased from 50% of overweight or obese men towards almost 60%, while around 55% of white men were overweight or obese in 1998 this number increased towards 75%. Furthermore, colored and Asian men experienced a high increase in obesity prevalence between 1998 and 2016 with an increase of almost 10% in overweight or obese colored men and a remarkable increase of 15% in overweight or obese Asian men, while black men remain experiencing low numbers of overweight and obesity, as only 20% of black men are overweight or obese in 1998 and this number hardly increased in

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17 2016. Moreover, non-urban male residents experienced a small increase in obesity prevalence of around 5%, while the obesity prevalence of urban residents remained quite stable. While there is a difference in obesity prevalence of around 10% between urban and non-urban residents, this difference is tending to decrease as the prevalence of obesity is growing among non-urban male residents. Within the category of education, primary educated and secondary educated men tend to have a slightly lower obesity prevalence than men without any education. This is quite remarkable as uneducated men tend to be occupied in the most physically demanding jobs, which should lead to an increase in output of the energy balance leading to a smaller risk to become overweight or obese (Alaba & Chola, 2014).

Figure 2: The percentage of overweight or obese men per social category in 1998 and in 2016

Figure 3 shows a similar graph as figure 2 but is focused on the percentage of overweight or obese women per social category between 1998 and 2016. What immediately stands out is that figure 3 shows much higher percentages of overweight and obesity than figure 2 shows, which means that in general more women are overweight or obese than men. However, unlike the obesity prevalence among men per social category the obesity prevalence of women is more equally distributed over the different social categories. Nonetheless, all social categories in figure 3 show quite an increase in overweight or obese women, indicating that overweight and obesity among women in general are increasing rapidly. Furthermore, the obesity prevalence among non-urban female residents has risen towards the level of the obesity prevalence among urban female residents, which indicates that there is no big distinction in obesity prevalence between rural and urban areas anymore. This could be explained by the fact that rural areas are increasingly showing urban trends, which leads to an increase of obesity prevalence. This phenomenon is further explained in the next chapter.

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Figure 3: The percentage of overweight or obese women per social category in 1998 and in 2016

4.2 The prevalence of overweight and obesity in 2016 per gender

As stated earlier, the SADHS of 2016 reports that 68% of women and 31% of men are either overweight or obese in South Africa, which indicates a heavily unequal distribution of obesity prevalence between men and women. Therefore, this section will look into this unequal distribution a bit more by focusing on how the percentage of overweight or obese differs between men and women per social category. In other words, the distribution of obesity prevalence among men and women will be analyzed per social category, by studying figure 4.

Figure 4: difference in obesity prevalence between men and women per social category in 2016

0 20 40 60 80 100

Residence Education Race

Difference in percentage overweight or obese between men

and women in 2016

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19 In almost every social category women have a higher percentage of overweight or obesity than men do, with the exception of white South Africans whereby there are more white men who are overweight or obese compared to white women. Furthermore, the difference between obesity prevalence among higher educated men and higher educated women is quite small. After the analysis of figure two this could be expected as both the categories of high education and white had the biggest obesity prevalence among men. Within the social category of race the biggest difference in obesity prevalence is visible among black women and men, as the prevalence of obesity is quite high among black women and the lowest among black men. This difference in obesity prevalence could be explained by a factor described in the next paragraph, cultural perceptions. Because of these cultural perceptions different body ideals are developed which could explain this difference in obesity prevalence. All in all, the obesity prevalence among South African women is quite evenly distributed over the social categories with the exception of the category of education whereby the prevalence of obesity is higher among primary educated women and higher educated women. Furthermore, the prevalence of obesity is more unequally distributed among men over the social categories, whereby the obesity prevalence especially among higher educated men and white men deviate from the other social categories. The even distribution of a high obesity prevalence over the social categories among women could explain why there is a higher obesity prevalence among women than among men. While among men only two social categories face a high obesity prevalence, among women all the social categories show a high prevalence for obesity.

4.3 Cultural perceptions towards body size and obesity

As explained in the previous section, some of the differences in the percentage of overweight and obese men and women can be explained by cultural perceptions towards body size and obesity. The SADHS of 1998 reports that 29.2% of men and 56.6% of women were either overweight or obese. However, only 9.7% of men and 22.1% of women actually perceived themselves as overweight (Puoane et al., 2002). These inaccurate perceptions tended to differ among different population groups, as white women’s perception of their body type was approximately the same as the actual numbers. Puoane et al. (2002) explain that black women tended to have the most inaccurate perceptions on their body size, which could be due to traditional and cultural perceptions of body size. In many black South African communities obesity and overweight are perceived to reflect good health, beauty and affluence (Puoane et al., 2002; Micklesfield et al., 2013). This results in a preference for a larger body size, especially among black women. This preference could explain why the obesity prevalence among black women is much higher than among black men. Furthermore, being thin and losing weight is associated with many negative connotations, such as times of anxiety and problems, while overweight has many positive connotations (Mvo, 1999). A study performed by Puoane et al. (2005) which identifies knowledge and perceptions on obesity and body size among black female community health workers in Khayelitsha, Cape Town, confirms this. The health workers explained that women should be round, which is associated with dignity, respect, health, affluence and strength, whereas being thin is associated with

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20 unhappiness, HIV or AIDS (Puoane et al., 2005). Although the health workers were aware of the negative consequences of overweight and obesity these women preferred to be overweight as being thin is severely stigmatized in the community to the extent that these stigmas overshadow the negative health outcomes of overweight and obesity (Puoane et al., 2005). This shows how much the community plays a role in the construction of an ideal body size and how this influences people’s attitudes towards obtaining an acceptable body size. Moreover, Mvo (1999) explains that many women in her study actually expressed discontent on their overweight bodies but that family members have positive feelings towards it. Puoane et al. (2005) explains a similar situation wherein the health workers express that thin women must feel better about themselves. This contradicts the many positive associations with being overweight and somehow shows that the perceptions of family members and the community contradicts the ideals of the women themselves. A study performed by Puoane et al. (2010) on perceptions towards body size among black girls in a township shows that being overweight or obese also carries negative connotations, such as the association with diseases as diabetes and hypertension. This indicates that people are aware of the negative consequences of being overweight. However, many girls resist to lose weight afraid to be associated with HIV or AIDS (Puoane et al., 2010). This shows an opposition between either being overweight and being associated with non-communicable diseases or being thinner and being associated with HIV or AIDS. It is evident that in the study of Puoane et al. (2010) many overweight girls are more afraid to be associated with HIV than with diabetes or hypertension. This could be due to the black communities’ history of poverty and food security, which impacts that overweight body types are more positively perceived (Renzaho, 2004; Mvo, 1999). This in turn could discourage women to lose weight as exercise and healthy eating habits are negatively perceived (Mvo, 1999: Puoane et al., 2005). Furthermore, exercise is tended to be viewed only as a mean to lose weight and not as a healthy activity (Puoane et al., 2005). Additionally, the changing beliefs of overweight women themselves, who rather want to be thin, could be explained by the influences of media which portrays thinness as attractive (Puoane et al., 2005). This creates a division in the social beliefs towards body size in black communities. On the one hand, women want to conform to the cultural values of their community, while on the other hand they want to conform to the values promoted by the media (Puoane et al., 2005). The study of Puoane et al. (2006) shows how this especially influences young women, as these women tend to have the desire to be thin and are therefore adjusting their eating habits to accomplish this.

The studies analyzed in this section confirm that historical issues with food security have influenced the cultural perception of the community towards ideal body size, which created many positive connotations with overweight and obesity. Furthermore, the theory that these perceptions have influenced the socialization process and people’s behavior towards lifestyles which promote overweight and obesity can be confirmed as well. It is evident that the beliefs of the community towards body size strongly impact the behavior of women, as stigmas towards being thin among the community often overshadow

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21 women’s growing desire to be thin. This desire to be thin, which exists especially among young women, could be the result of the growing influence of media. Resulting in opposing beliefs towards body size within the community, while the most part of the community values overweight body types many young women have an increasing desire to be thin. Furthermore, the study of Puoane et al. (2010) reports that there is a growing awareness of the health outcomes of overweight and obesity, as it is being associated with non-communicable diseases as diabetes and hypertension. Besides, the female health workers in Khayelitsha showed to be aware of the health outcomes of overweight and obesity as well, but still chose to be overweight as the influences of the community’s cultural beliefs weighed heavier than the risk to develop non-communicable diseases.

4.4 Concluding remarks

This chapter has presented how overweight and obesity are visible in South Africa, in terms of actual numbers and statistics as well as in terms of cultural beliefs towards overweight and obesity among black South African communities. It is evident that women in general have a higher BMI than men, with an average BMI of over 25, indicating overweight, in almost every social category in 1998, which further increased in 2016. Among men, especially higher educated and white men stand out from the other social categories, in terms of average BMI as well as in prevalence of obesity. While black men tend to have the lowest BMI and the lowest obesity prevalence throughout 1998 to 2016. Another interesting finding is that the BMI and obesity prevalence of urban and non-urban men and women does not differ as much as expected and that the percentage of overweight or obese men and women in non-urban areas is increasing towards the percentage of overweight or obesity in urban areas. This indicates that obesity is now becoming as much as a problem in rural areas as it has been in urban areas. Besides, the obesity prevalence among women tended to be more equally distributed over the social categories, indicating that there is not a particular social group among women who are vulnerable for obesity, but that rather South African women in general are vulnerable for obesity. However, the biggest difference in obesity prevalence between gender and the social categories was between black men and black women. This has something to do with the cultural perception towards overweight and obesity among black communities, as these have been the communities who have been historically most deprived in terms of food security, which has a major influence on the cultural perceptions towards body size and beauty. These cultural perceptions towards body size among the community put great pressure on women to reach a bigger body size even though more people are becoming aware of negative health outcomes of being overweight or obese. It shows that stigmas among the community weigh heavier than the risk to develop a non-communicable disease. However, a moving desire away from bigger body size towards being thin is more and more common among young black women, which contradicts with the cultural values in the community.

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5. Socioeconomic causes for obesity in South Africa

This chapter analyzes how socioeconomic factors as globalization, economic growth and urbanization influence the rising obesity rates in South Africa. Firstly, this chapter focuses on the impact of globalization on changing food patterns which promote overweight and obesity by analyzing how big international food organizations, such as supermarket and fast food chains, have spread over South Africa and what the consequences are for South African’s dietary habits. Secondly, the effect of urbanization on South Africa’s high obesity prevalence is analyzed, by focusing on the effects of urban residency on dietary and physical activity patterns. Furthermore, the possible explanations for the decrease in disparities in obesity prevalence between urban and non-urban residents, which was visible in chapter four, are discussed. Thirdly, this chapter looks into the influences of economic growth on the rising obesity rates, by mainly focusing on economic growth in terms of SES. Finally, this chapter concludes with some concluding remarks on the effects of these socioeconomic causes on the high obesity prevalence and on how these factors interact.

5.1 Globalization

As explained in the theoretical framework, global market forces, such as modern food processing, marketing and distribution techniques, have led to the expansion of multinational fast food chains and supermarket chains, which serve low in nutritional value types of food, facilitating the nutrition transition towards unhealthy Western dietary habits. On top of that, these global market forces lead to declining food costs as food is more often produced in larger volumes, causing a decrease in food prices of foods low in nutritional value. The nutrition transition in its turn, promotes a positive energy balance causing people to be overweight or obese. Numerous studies on the expansion of big food companies in South Africa confirm these theories and show evidence in high increases of sales in sugary beverages and calorie-dense foods (Igumbor et al., 2012; Crush & Frayne, 2011; Battersby & Peyton, 2014). Another major finding of these studies is that these fast food chains and supermarket organization have not only expanded into urban areas, as described in the theoretical framework, but have expanded into rural and lower-income urban areas as well, facilitating rural residents and people from a lower SES into a nutrition transition (Adeniyi et al., 2015; Igumbor et al., 2012; Weatherspoon & Reardon, 2003; Louw et al., 2008). This section describes the expansion of big food companies in South Africa and its consequences for the rising obesity prevalence. Besides, it analyzes how global market forces have penetrated in rural areas and what the resulting effects in food security and dietary habits are.

Supermarket chains in South Africa rapidly began to grow at the end of apartheid in 1994 (Weatherspoon & Reardon, 2003). The supermarket sector has grown to a share of 68% of the total food retail market in 2010, whereby only four major supermarket chains, Pick n Pay, Spar, Woolworths and Shoprite,

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23 dominate the supermarket sector with a share of 90% (Battersby & Peyton, 2014; Igumbor et al., 2012; D’Haese & Van Huylenbroeck, 2005). As chapter four has reported the overall obesity prevalence of men and women have increased rapidly in almost the same time period, from 1998 to 2016. This may indicate that the rapid spread of supermarket chains which began in 1994 could have a share in this. Drivers of this supermarket expansion on the demand side could be growth of income, urbanization, a growing number of women entering the labor force and improved household storage capacity, while drivers on the supply side could be global forces such as the increase in retail foreign direct investment and the modernization of supermarket procurement systems (Battersby & Peyton, 2014; Louw et al., 2008). It is evident that a nutrition transition has occurred, accompanied by the rapid expansion of the supermarket sector as this expansion has led to an increase in import of ingredients used in processed food, which are low in nutritional value (Igumbor et al., 2012; Battersby & Peyton, 2014). Supermarkets often sell foods for lower prices than in traditional retail stores, especially processed foods, due to economies of scale and the production of large volumes causing supermarkets to cut down in prices, making food more affordable for South Africans (Igumbor et al., 2012; D’Haese & Van Huylenbroeck, 2005). This seems positive as it can decrease food insecurity, that many South Africans face. However, healthier foods are much more expensive than less healthy foods in supermarkets, which creates an economic incentive for many South Africans, especially people from a lower SES, to consume food low in nutritional value but high in energy, such as refined cereals and foods with added sugars and fat (Igumbor et al., 2012). This shows that through global market forces supermarket chains can make unhealthy western foods affordable and hereby facilitate the rising obesity rates.

Besides changes in food patterns, the expansion of supermarket chains has another major consequence, namely the limitations on the food market for local retailers not only in urban areas but in rural areas as well, which leads to negative consequences for people from lower SES who were allowed to buy food on credit from traditional retailers (Battersby & Peyton, 2014). Due to growing disposable income among South African consumers, the rapid growth of the black middle class after apartheid and competitive pressure among supermarket chains supermarkets have expanded towards townships and rural areas (Weatherspoon & Reardon, 2003; Battersby & Peyton, 2014). The penetration of globalization and supermarket chains in these areas eradicates local stores and created a large dependence on big food organizations for food (Crush & Frayne, 2011). This can be problematic since, supermarkets are sources of cheap energy-dense and high in fat and sugars foods, while traditional retailers were sources of quality fresh produce, causing rural people and people living in urban settlements to enter the nutrition transition like their urban counterparts. D’Hease & Van Huylenbroeck (2005) report that even though there is no supermarket within the rural community, households still go shopping at the nearest city’s supermarket, since the advantages of lower priced foods outweigh the transportation costs. This indicates the strong position of the supermarket chains in the food retail market in South Africa and shows how global market forces as quicker production and distribution methods contribute to this, leading to further limitations on the food market for traditional retailers. The study of

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24 Adeniyi et al. (2015) on the obesity prevalence and the determinants of obesity among type 2 diabetes patients in rural communities in the Eastern Cape confirms that the consumption of Western style foods is an important determinant for obesity, as they reported an obesity prevalence of 98,2% among their participants who did not take in vegetables but did consume Western types of food on a regular basis.

Besides the rapid expansion of supermarket chains, the expansion of multinational fast food organizations and other big food companies is a notable outcome of globalization in South Africa. Fast food chains developed strategies to make their products more available on the food markets. For example McDonald’s only entered the South African market in 1998 and in six years’ time it opened 103 restaurants and is currently operating over 200 restaurants over all nine South African provinces (Igumbor et al., 2012; McDonald’s SA, N.D.). Besides, in an interview of 2013 McDonald’s South Africa managing director stated “it is time for us to stretch our wings to rural and small town parts of South Africa or in places where the brand is not represented.” (Magwaza, 2013), indicating that besides supermarket chains fast food chains are now penetrating the market in rural areas as well. However, Igumbor et al. (2012) reports that still a bigger share of the population buys food from street vendors than from fast food restaurants, as 6.8% of the South African population buys food from fast food restaurants and 11.3% of the population buys food from street vendors at least two times week. Steyn et al. (2011) describes that both street food stalls and fast food outlets are a source of calorie-dense foods and high in sugar beverages and that these contribute to a shift from traditional foods towards Western style foods. The difference between the two is that street vendors usually sell foods at a lower price, making food more affordable and accessible for people from a lower SES, and have less variety in their products (Steyn et al., 2011). Research on the consumption of fast food, sold from both fast food outlets and street food vendors, of adolescents around the area of Johannesburg reports that 30% of the participants consumed fast foods five to seven times a week, while 20% of its participants consumed it two to four times a week (Feeley et al., 2009). Global market forces have not only made the expansion of fast food outlets possible but also penetrated within the informal sector, whereby big food companies got involved with street vendors to make their products available (Igumbor et al., 2012). For example, Coca-Cola created incentives for people to start street vendors in townships in order to increase their sales through the network of informal traders, as by 2005 95% of the informal outlets in townships sold Coca-Cola products (Igumbor et al., 2012). This shows how powerful big food companies are in infiltrating the market on different levels and how hereby their products are widespread sold over the country.

The theories proposed in the theoretical framework which state that globalization has led to greater food availability and affordability through the spread of big food organizations, especially supermarket and fast food chains, can be confirmed. It is evident that supermarket chains have taken over a large share of the food retail market, selling especially unhealthy foods against low prices, while healthier foods are sold for a higher price. This makes unhealthy, Western types of foods, more available for a bigger part

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25 of the South African population. While on the one hand this could solve the problem of food insecurity for many South Africans, on the other hand it exposes them to a nutrition transition existing of foods high in fat and sugars, making people more vulnerable for overweight and obesity and related non-communicable diseases. On top of that, the theoretical framework has stated that urbanization facilitates the expansion of large food companies, making especially urban residents vulnerable for unhealthy changes in diet, but the study of numerous researches highlighted a movement towards rural areas and urban settlements as well. This movement exposes a larger part of the South African population to unhealthy Western diets, making more and more people vulnerable for overweight and obesity. This indicates the power of globalization, transforming South Africa’s food retail market on all levels and hereby changing the diet patterns of both urban and rural South Africans from different SESs and in this way impacting the high obesity rates of South Africa.

5.2 Urbanization

Urbanization influences the obesity prevalence due to changes in built in living environment, a broad range of food options and lifestyle changes related to technological advancement, causing people to change their dietary habits as well as their patterns in physical activity. This in turn leads to a positive energy balance causing people to be overweight or obese. This section analyzes whether these theories could be confirmed in the case of South Africa and looks into the effect of urbanization on dietary intake and physical activity patterns, which could have an effect on the obesity prevalence.

Multiple studies show that the prevalence of obesity is much higher in urban areas compared to rural areas in South Africa (Alaba & Chola, 2014; Puoane et al., 2002; Micklesfied et al., 2013). While in rural black communities infectious diseases associated with undernutrition are prevalent, urban and urban-dwelling communities face a rising prevalence of non-communicable diseases associated with overnutrition (Micklesfield et al., 2013). The nutrition transition, which is accommodated by urbanization, is seen as one of the causes of these differences. Compared to other Sub-Saharan African countries, South Africa is considered further along the nutrition transition, which goes along with higher intakes of energy and higher intakes of fat and sugar (Micklesfield et al., 2013). Differences in urban diets are attributed by an increase in women’s employment and the time constraints of urban life, which causes a preference for the consumption of easy to cook or pre-cooked foods (Louw et al., 2008; Battersby & Peyton, 2014). Puoane et al. (2006) confirm that people who move to urban settings abandon traditional foods, such as grains and greens and adopt foods which are associated with status, such as meat and fast foods, while traditional foods are associated with poverty. Thus, urbanization leads to a dietary shift, whereby more fats and energy-dense foods are consumed. Urbanization is associated with an increase in dietary fat intake, which corresponds with higher obesity prevalence in urban areas than in rural areas (Micklesfield et al., 2013). This is confirmed by Kruger et al. (2005) who report that the average urban residents’ caloric intake consists of 30.6% fat, compared to 22.9% of fat intake among rural residents. The fast degree of urbanization that black South Africans were undergoing since

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post-26 apartheid times, resulted in an increase of fat intake of 10% among the urban black communities (Puoane et al., 2002). Furthermore, nutrition quality tends to be especially poor in peri-urban black communities, having lower food variety through low household food security (Micklesfield et al., 2013). This is due to the fact that most black South Africans who urbanize tend to live in informal settlements which may not be situated close to food chains which offer greater variety of quality food. Thus, the most convenient place to purchase food from is from informal vendors who sell inexpensive, poor quality and low in dietary diverse foods, which disadvantages food availability and food security for residents of townships (Steyn et al., 2011; Micklesfield et al., 2013). On top of that, people who live far from their work, which is often the case in urbanized areas, may not have regular meals at home due to long travel distances, and will therefore buy food from street vendors at low costs (Steyn et al., 2011). This indicates how urbanization influences people’s food consumption behavior leading to unhealthy changes in diet making people more vulnerable for overweight and obesity. However, the section on globalization has illustrated that the nutrition transition is penetrating within rural areas and urban settlements, causing a decline in disparities between rural and urban areas. This decline in disparities of obesity prevalence between urban and non-urban areas is also visible in the statistics presented in chapter four. The statistics showed that the average BMI of men and women differs not that much in urban and non-urban areas, as the average BMI of men in urban areas was 23.9 and in non-urban areas was 23 in 2016 (SADHS, 2016). The average BMI of women in urban areas in 2016 was 29.6 and 28.6 in non-urban areas (SADHS, 2016). Furthermore, the obesity prevalence in non-urban areas significantly increased between 1998 and 2016 with 14.8% among women and 4.2% among men. These number represent the movement of big food companies into rural areas, which causes rural residents to enter the nutrition transition as well. This would indicate that the convergence between rural and urban areas is contradicting with earlier studies, which show major differences in nutritional intake between urban and non-urban residents (Puoane et al., 2002; Kruger et al., 2005; Puoane et al., 2006; Micklesfield et al., 2013).

The SADHS from 2003 reports that physical activity levels reduce with increasing urbanization. The overall prevalence of physical inactivity is estimated to 48% in women and 45% in men (Micklesfield et al., 2013). Studies have shown that physical activity correlates stronger to obesity than SES and dietary factors, thus high levels of physical inactivity could be directly linked to the development of obesity (Micklesfield et al., 2013). Kruger et al. (2002) confirms this as their study shows that their most inactive participants were also the most obese. They also report that physical inactivity may be one of the most important factors affecting BMI among black women. Poor environmental conditions could act as a barrier to physical activity, as studies show that physical activity is significantly higher in neighborhoods where crime occurs less (Kruger et al., 2005; Micklesfield et al., 2013). On top of that, as explained in chapter four, cultural values act as a barrier for physical activity as physical activity is associated with weight-loss and weight loss is associated with having HIV or AIDS (Puoane et al., 2010). On top of that, the increasing amount of time that people watch television contributes to

The rapid increase of overweight and obesity rates in South Africa : a study on the determinants and the socioeconomic causes for obesity