28 November 2011

HIV/Aids stigma fuels obesity in SA

The obesity epidemic in South Africa is being fuelled by the belief among black women that thinness is a sign of HIV/Aids infection, a new study has found. DietDoc takes a look.


The obesity epidemic in South Africa is being fuelled by the belief among black women that thinness is a sign of HIV/Aids infection, a new study has found. DietDoc takes a closer look.

Body size perception is known to be influenced by a variety of factors. In previous centuries, well-endowed people, and particularly women, were regarded as symbols of affluence, beauty and fertility, and it is only in recent times, what one could call the post-Twiggy era, that thin, emaciated bodies have become the ideal that women strive for.

Roles of culture and the media

Culture also plays an important role in how individuals view their bodies. For many years there has been a considerable difference in the concept of ideal body shape between people of African origin and those of European descent, not only in our own country, but also in other parts of the world.

Media pressure and the example set by film stars, models and other public figures, also tend to determine how you view your body size and how satisfied you are with your contours or lack of them. Some research has for example, indicated that black teenagers and young women who are part of the pop generation, go to unprecedented lengths to lose weight. In fact the incidence of anorexia and other eating disorders is increasing in this section of our population (Senekal, 2009).

The HIV/Aids effect

I was, therefore, interested to read a recent publication in the SA Journal of Clinical Nutrition by Matoti-Mvalo and Prof Thandi Puoane (2011), that has identified how the perception of body size in South Africa (and probably in other parts of our continent) has now become influenced by the HIV/Aids pandemic.

These researchers set out to determine how women living in Khayelitsha, the largest urban black township in Cape Town, viewed the size of their bodies and if HIV/Aids had impacted on their perceptions. The study was undertaken because of concern that wrong body size perceptions may be fuelling the obesity epidemic in this country.

With a prevalence of more than 54% of obesity found in urban women, and black urban women being particularly vulnerable, the authors of this paper were gravely concerned that just when people “should be avoiding risk factors for cardiovascular disease, especially obesity, many are becoming obese to avoid the stigma associated with being infected with HIV or having Aids” (Matoti-Mvalo & Puoane, 2011).

The Khayelitsha Study

Phase 1

513 randomly selected women over the age of 18 years, were included in the first phase of the study. A variety of data were collected from the participants such as body-image perception, body weight and height, access to health care, food consumption patterns, and level of physical activity.

To explore perceptions of body size and image, the subjects were shown eight figures specifically adapted for use in the South African population, depicting body shapes that ranged from very thin to very obese. The participants were then asked:

  • Which image would you like to be?
  • Which image symbolises good health?

  (Matoti-Mvalo & Puoane, 2011)

Results of Phase 1:

Body weight perceptions

  • 69.3% of the women associated the underweight figures with being infected with HIV or having Aids
  • 10.2% associated the thinnest figures with health and 8.4% said that they would prefer to be underweight
  • 50% of the subjects preferred the normal-weight category of figures and 34.2% associated normal weight with health
  • Surprisingly 33.5% of the women preferred being in the overweight category and 31.4% thought that being overweight symbolised health
  • Although few women wanted to be in the obese category (only 7.8%), 24% said that being obese symbolised health.

(Matoti-Mvalo & Puoane, 2011)

Incidence of overweight and obesity

207 of the 513 subjects were overweight (40.3%), and 77 or 15% of these overweight women thought that being overweight was acceptable. Similar results were obtained for obesity with 217 subjects or 42% of the participants being obese and 13% believing that being obese is acceptable. Only 40 (8%) of these women perceived themselves as being obese (Matoti-Mvalo & Puoane, 2011).

In other words, Phase 1 showed that nearly 70% of the women who participated in the study believed that thinness is a sign of HIV/Aids infection. One third of the women actually preferred being overweight and regarded overweight as a sign of health. The study population had a high incidence of overweight (40.3%) and obesity (42%) and up to 15% of these women believed that being overweight or obese, is acceptable.

Phase 2

In the second phase of the study, 10 women from the group that linked being thin with HIV/Aids, and 10 women who did not, were selected to take part in focus group discussions to investigate their attitudes, beliefs, and knowledge of HIV/Aids (Matoti-Mvalo & Puoane, 2011).

Results of Phase 2

The results of Phase 2 showed that members of the group who associated thinness with HIV/Aids, believed that being thin was an indication that a person was suffering from HIV/Aids, and that other diseases such as TB or diabetes were not implicated because HIV/Aids was regarded as the prime cause of thinness. The other group had opposing views, but both groups displayed little knowledge of how a person becomes infected with HIV.

Matoti-Mvalo & Puoane (2011) concluded that cultural beliefs still exerted an influence on the beliefs of the women who were interviewed, despite the fact that more than half of them had a high school education. The pro-overweight group believed that it is better to be overweight because this protects people from being stigmatised. The following quote poignantly illustrates how these women regard thinness: “If you have Aids and suddenly gain weight, people believe that you are well again” (Matoti-Mvalo & Puoane, 2011).


This is the first study to explore the perception that urban black women in South Africa believe that people who are thin are infected with HIV or have Aids. In this study group, having a large body size was thus regarded as desirable to protect against stigma, shame and discrimination, which are unfortunately still associated with HIV/Aids all over the world (Matoti-Mvalo & Puoane, 2011).

The authors concluded that “the stigma attached to being infected with HIV or having Aids may be responsible for fuelling the obesity epidemic among black African women”(Matoti-Mvalo & Puoane, 2011).

So while many patients living with HIV/Aids struggle to maintain a healthy weight, the negative perceptions thinness creates in our population could well be one of the causes of the soaring obesity statistics. Body perception is not a simple concept and it will take a great deal of education and effort to change the perceptions of the African population here and elsewhere on this continent, that being thin does not automatically mean that you are ill, and that having a normal body weight is a desirable goal.

- (Dr IV van Heerden, DietDoc, August 2011) 


(Matoti-Mvalo T, Puoane,T (2011). Perceptions of body size and its association with HIV/AIDS. SA Journal of Clinical Nutrition, Vol 24(1):40-45; Senekal M (2009) A continuum of weight management related problems: from classic eating disorders to obesity. Paper presented at the Sugar & Health Symposium, Eastern Cape, East London. 12-13 May 2009.)

Any questions? Ask DietDoc

Read more:

Sociocultural aspects of HIV/Aids
Understanding HIV stigma essential
Stigma and ignorance in Africa
Fat South Africans in denial


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