Perceptions of overweight African women about acceptable body size of women and children

Purpose: Malnutrition, presenting as obesity in women and under-nutrition in chil­ dren, is a prevalent problem in the squatter communities of Cape Town. Food hab­ its are determined by a complex matrix of economic, social and cultural factors which need to be understood by health professionals prior to the implementation of strategies to improve the nutritional status of this community. This qualitative study is designed to explore the perceptions of overweight black women in Cape Town, with underweight infants, about the culturally acceptable body size for women and


INTRODUCTION
H ealth p ro v id e rs , w h ils t w o rk in g am ongst the low est so cio-econom ic groups in South Africa, are faced with a confusing anomaly; many mothers who present with undernourished infants and children at primary health care clinics are observed to be grossly overweight.Balanced nutrition is recognised to be the cornerstone of maintaining an opti mum level of health, and efforts to im prove the dietary habits of all members of the South African population remains a priority.Food security, patterns of food preparation and child rearing practices are determined by a complex matrix of social, economic and cultural variables.The observation that malnutrition in in fants and over-nutrition in mothers co exist in the same family suggest that food scarcity or excess may not be the only factors involved.(13, ') Health providers need a clear insight into Curationis June 1999 27 the factors associated with under-and overnutrition prior to designing and im plementing interventions to improve the health status of communities.Effective culturally sensitive nutrition programmes need to be based on an understanding of women's values concerning body size and perceptions of health.It is the aim of this study to explore some of these perceptions using a qualitative research m ethod in the squatter com m unity of Khayelisha, Cape Town.Qualitative research attempts to under stand the meaning and the behaviour from the perspective of the participant (10).In this approach the interpretation of the data emerges from an interaction between inform ants and researchers.The research becomes a recursive proc ess of purposive sampling, collection, categorisation and interpretation of data

U nd er-n u tritio n in in fan ts and children
Malnutrition results from the inadequate intake of nutrients or from disease fac tors which affect the digestion and utili sation of nutrients.Infectious diseases have been shown to negatively affect both dietary intake and digestive proc esses (8).Dietary intake depends on four factors: the meal frequency, the amount of food per meal, the energy and nutrient den sity of the food and the biological utilisa tion.Some studies |97) have shown that p ro te in -e n e rg y m a ln u tritio n , h ig h ly prevalent in developing countries, ap pears fre q u e n tly d u rin g the in fa n t's weaning period from 4 to 18 months of age.This is due to high energy breast milk being substituted by food which may be in scarce supply.In South Africa p ro lo n g e d b re a s tfe e d in g a p p e a rs underutilised as a means of dealing with food scarcity.Under-nutrition in infants and children resulting in the stunting of the growth process, is closely associated with increased infant mortality, retarded mental development and an increased risk of developing infection < 12).

O ver-nutrition in black w om en
Until the age of 14-15 years at least 50% of black South African children are un der the 3rd percentile of weight for age of the Boston reference standards(1).The situation changes at adolescence, when approximately 50% of black females be come obese, i.e. with a Body Mass In dex (Weight (Kg)/ Height (m2) > 30 (1).On the other hand, obesity am ongst black males remains rare (8), despite the fact that both sexes consume the usual high fibre, low animal fat and low pro tein diet with similar amounts of sugar consumption.Although it is suggested that black males are more physically active, experts regard physical activity as being only part of the explanation of the g e n d e r d iffe re n tia tio n in b o d y size amongst the South African black com munity.International literature indicates a wide range of biological, psycho-social and cultural factors that contribute to the problem of obesity.While excessive ca loric intake may lead to obesity, but may not be a factor in maintaining obesity once established <6' 411).Although indi vidual requirements for food energy, nu trients and psycho-social nurture do not vary significantly from one society to an other, the resources to meet these needs may vary considerably.Overnutrition in adults is associated with the increased risk of developing non-com m unicable disease such as hypertension, diabetes, cardiac disease and certain types of car cinoma <3).

Perceptions of body im age
Most studies on obesity and body im age have been conducted in America.Stevens et al (11) explored the associa tion between attitudes to eating with the perceptions of body size in obese eld erly black and white women.The find ings indicated that in the USA black women were more satisfied with their body size than white women.This sug gests differences in cultural attitudes to wards large body size.A similar study by Kemper (5) showed significant differ ences between black and white adoles cents perceptions of body size.In this project, adolescent fem ales were re quested to select from a wide range of illustrations "an ideal female body size" in order to explore the norms and expec tations of family and friends.The black adolescents were more likely to select a larger body size than their white coun terparts.They perceived that their par ents considered them thin, while white adolescents thought their parents con sidered them " heavy" .It became clear from this study that families and comm u nities play a significant role in influenc ing standards of appropriate body size.

Study aim
To explore the perceptions of overweight black women in Cape Town, with under weight infants, about the culturally ac ceptable body size for women and chil dren.

METHODS
A qualitative study was im plem ented using in-depth interviewing techniques (2)to explore the cultural perceptions of body size of obese mothers with under w eight children.The study was con ducted in Khayelitsha, a large area of formal and informal housing in the met ropolitan area of Cape Town.A snowball technique of sampling was utilised( 2)to make contact with potential in fo rm a n ts .The w om en w ere a p proached while attending the primary health care clinic in Khayelitsha.Redun dancy of descriptions, a means of de termining sample size in qualitative stud ies, occurred during the ninth and tenth interview.Sampling criteria were that the women be between the age of 18 and 45 years, black and Xhosa speaking, obese, and yet mothers of children de scribed by the clinic nurses as under weight.All participants lived in a squat ter community of Khayelitsha, which ac com m odates many black fam ilies re cently migrating from rural areas to Cape Town in search of employment.Partici p an ts w ere a p p ro a c h e d by the re searcher who requested their participa tion in the study.The researcher o b tained informed consent from each par ticipant and permission to record the in terviews on audio-tape.The interviews were held in the clinic setting while participants were waiting for a health provider consultation.The in terview was routinely preceded by a cul turally appropriate introduction of the researcher's cultural and professional background.All interviews were con ducted in Xhosa which was the first lan guage of both the participants and the researcher conducting the interviews.Probes specific to eliciting perceptions of body size and body size values of adults and children were elicited.Inter view ing data conce rn ing the p a rtic i pant's ideas of desired body weight, what was considered attractive and the relationship between health and body mass was also discussed.These probes included family and peer perceptions of weight gain or weight loss and the rea sons for either gaining or losing weight.Food habits, food preparation and the

"A n d / c o u ld s e e t h a t w ith th e D e p o in je c tio n a m n o lo n g e r h a v in g th e b o d y / u s e d to
choice of foodstuffs were also discussed.The mean duration of each interview was 45 minutes.The tapes were transcribed and then translated from Xhosa to English by the researcher and an assistant.The analy sis of the content and techniques of con stant comparison |2) were used to ana lyse the tra n scrip ts into categories, themes and contexts related to body size values and factors which influence those values.The reliability of the process of analysis was enhanced by having two colleagues review categories and con text independently.The level of agree ment using this process was very high.The results are reported as themes as is customary in qualitative research.

Dem ographic d a ta
All the participants interviewed in the study had moved to Cape Town from the Eastern Cape region of South Africa; nine of the ten informants coming from the rural areas, whereas one came from the city of East London.The age range of the sample was from 18 to 36 years of age.All participants were mothers; most unmarried; and 9 out of the 10 partici pants unemployed.All participants lived in the shack communities of Makhaza, Site B and Site C in the su b u rb of Khayelitsha with households of 4 to 10 other occupants.One of the participants had left school after 6 years of schooling, while the rest of the group had received 9 or 10 years of formal education.Due to the high un employment rate in this group of partici pants, food security was problematic, many of them relying on the generosity of their householders who supplied the food.Most of the respondents received no financial support from the fathers of their children.

U nder*nutrition in in fants and children
Most of the mothers described their ba bies as being "big at birth" , but early in infancy the baby ceased to gain suffi cient weight, "He is smaller now, he was fat before".This perception was rein forced by observations made by health providers at the primary health care clin ics, "Even the nurses said that".The mothers gave a variety of reasons as to why their infants failed to thrive.Many described the fam iliar cycle of ceasing to breastfeed as a result of seek ing employment to supplement the fami ly's scarce resources, "She does not have proper food, nobody is working".The infant was then placed in the care of a childminder, who was not reliable; "My aunt is a drinking person"; "I dis covered that she was not treating him well"; " She does not care about things".Some of the mothers described the child suffering from diarrhoea, followed from a period of hospitalisation.The m others d e scrib e d vegetables, eggs, cereal and milk as appropriate food for their children."What I think would really make him gain his weight is spoon food".The main source of information regarding what to feed the child was the clinic nurse.The recurring problem was expressed as "Because they all (babies) stop breast feeding very early due to ill health.Then I have to feed them".The mothers usually made a type of porridge for the child's breakfast.The porridge may be accom panied with sour milk (amasi), soup or supplem entary milk products such as SMA, Lactogen or Nestum.Some mothers supplemented bread flour for porridge."I cook bread flour and pour it in his bottle".Other meals consisted of a mixture of cooked vegeta bles including rice and potatoes.A few mothers had problems feeding the child vegetables as the child did not like the food.
"R eally he does n o t lik e vegetables...you have to hold him and force him to eat".Most mothers expressed a wish for the child to have a big body.One exception was a mother who associated plum p ness with chest problems, "When the child is too big she is troubled by chest wheezing".The mothers who reported getting food (milk) for her child from a Malnutrition Centre complained that the milk is lim ited to two tins every fortnight.They de scribed the long wait, " You stay there from the morning till late"."You have to wake up at six as if you are going to work so that you can get the porridge to feed your child with".When asked if the chil dren do get enough food from these centres, one mother replied, "Yes, they get enough food although you have to struggle to get that food.It is said that it is the place to feed children but you see people having up to three dishes in front of them.One is for herself, the other one is for the child, and the last one is for her self again".

M others' perceptions of th e ir own body size
All the mothers described themselves as "fat".Many blamed their large body size on the contraceptive injection, Depo Provera."And I could see that with the Depo injection am no longer having the body I used to have...".Most of the women did not weigh themselves on a regular basis.They described them selves as fat because their clothes no longer fitte d them , or because they heard other people comment about their large size.Responses to the question on how the women felt about their body size varied.Some women felt that they were content with their shape as they associated be ing thin with times of stress and difficulty." I think I experienced a lot of problems at my husband's home.Then I lost and lost weight".When asked if they were satisfied, they responded with replies such as, "Yes, I like it".They were con tent with their body size as they felt healthy and were not limited in their daily living activities.However, the majority of women expressed discontentment with their bodies, "I wish I could loose weight, and not be like this.... " The women who expressed their discon tentm ent with their shape, gave three main reasons fo r their unhappiness.Firstly, they found that they were unable to wear clothes that they had previously enjoyed wearing, or that had been do nated to them.Secondly, they expressed difficulty m oving around, "No, it (the body) is heavy when you walk".Others felt uncomfortably hot during the sum mer days, "When it is hot I get a rash and I become very hot".The attempts to loose weight were lim ited.One woman described that she drank lemon juice with black tea, while another described her attempts to re strict her eating habits.These attempts soon failed when she was placed in a situation with abundant food, 7 some times try and not eat.My problem is that I can stay and not eat meat for some time, but when I eat it again, I eat it to make up for the times I was not eating it!"The response of people close to the women varied considerably.Many fam ily members and friends appeared to ac knowledge the participants' large size without any negative feelings."They say, "Wow, I wonder where do you get such a big body?"or "Yes, they do comment, but they do not criticise.They just talk about the fact that I have gained.".Oth ers described positive comments about their large size."He (husband) praises m e".A few w om en gave incidences when they had received negative com ments about their largeness."I work with coloured people, and they say I like food, that I am always eating, and that is why I

" I w is h / c o u ld lo o s e w e ig h t, a n d n o t b e lik e t h i s . . . "
am so fat".Many of the women associated weight gain with the prescription of the inject able contraceptive Depo Provera."No, its the Depo.......I became fat when I started using it".Others put on weight when they became worried and upset.This was som etim es associated with long periods of unem ploym ent, "Not working forces you to eat because you are not doing anything".Others con nected their obesity to excessive eating, "It is caused by food.I do not even want to lie.I like food very m uch"."I think maybe it is caused by eating too m uch".Sometimes the increased access to food was caused by happy circum stances such as getting a job or living with a gen erous relative.

DISCUSSION
This qualitative research study was de signed to explore the perceptions of "de sired body size" of a group of obese black women with undernourished in fants and toddlers.It forms an initial part of a bigger project that will be investi gating the determ inants of obesity in mothers and under-nutrition in children.The sample was obtained from women w a itin g fo r a c o n s u lta tio n at th e Khayelitsha primary health care clinic.This clinic serves a large residential area consisting of informal housing, and most of the women had recently translocated from the rural areas of the Eastern Cape.All but one of the mothers were unem p lo y e d and u nm a rrie d , and c o n s e quently had no source of secure income.The mothers told the familiar story of the inability to sustain breastfeeding, a prob lem which was related to a cycle of in fection and the failure to thrive.Only one of the mothers was able to breastfeed for a period as long as three months.The reasons given for ceasing to feed the baby on the breast were often associ ated with the need to search for some means of employment.The infant was fre q u e n tly p ut into th e ca re o f a childminder who was not conscientious in the care of the child.The main source of information regarding the feeding of the children was the clinic nurse, and in most circum stances the mother knew what she should be doing regarding the weaning of the infants.The children were often difficult to feed and it appeared obvious that these mothers needed the continual support which they obtained from professional health advisors.The encouragement of new mothers in initi ating and maintaining breastfeeding in these informal settlem ents remains a priority.All the mothers desired their babies to be plump with the exception of one mother who associated a fat baby with chest problems.Most of the women interviewed associ ated their weight gain with the use of the contraceptive (Depo Provera) injec tion.A few could recognise the associa tion of long periods of inactivity with overeating, especially when they were in situations where regular access to food was not assured.They communicated their association between food, pleasure and comfort.Thinness and loss of weight were associated with times of anxiety and problems.The women interviewed did not weigh themselves routinely, and their percep tion of the body size was generated by comments from peers and the inability to fit into clothes that had been previ ously comfortable for them to wear.Al though there had been recognition of their weight gain by their peers, this ac knowledgement was not associated with any negative social connotations.In fact some participants had had positive feed back regarding their attractiveness from people significant in their lives.Negative comments quoted had come from mem bers of another ethnic grouping.The women who were unhappy about their obesity gave practical reasons for their dissatisfaction, such as feeling un comfortably hot or heavy, or not being able to wear the clothes that others had given them.None of the women identi fied potential health reasons as a moti vation to loose weight.The descriptions participants gave to reduce their body mass, indicated that they had little knowledge of an effective strategy to achieve their aim.Their at tempts to restrict their dietary intake were sporadic, and interspersed with periods of overeating.The use of black tea, with out changing aspects of their diet, also indicated a poor understanding of the physiological basis of weight reduction.The m ism a tch b etw een p e rce ive d causes of weight gain and the ways of losing weight is highlighted by this study.The focus on energy balance which cur rent w eight control program m es pro mote does not deal with the perceived causes of weight gain in this community.Although the transferability of results of this study are limited, there is an indica tion of the possible causes of the prob lems of obesity in women and undernu trition in children in this particular com munity.Factors associated with difficul ties in m aintaining prolonged breast feeding in this under privileged commu nity need to be explored further.The in troduction of successful weaning prac tices in this type of community remains an important health priority.

CONCLUSION
These issues will be systematically inves tigated in a quantitative study designed to obtain a comprehensive overview of the issues associated with both under nutrition and over-nutrition in this com munity.This descriptive research is per ceived as an essential component of the process of developing effective health promotion programmes for similar com munities.Effective health promotion in terventions need to be based on a clear understanding of the cultural values concerning body size, p atterns of food preparation and child rearing practices.