Last month, WHO published a report based on a survey of the health of 3,281 adults in Swaziland. Compared with other countries, few people smoke – just 6% on average, mainly middle aged men. Alcohol consumption is lower too, with just a quarter of Swazis drinking, though men tend to be more excessive.
As you may have read in a previous posting, the Swazi diet is heavy in starch. Only 8% of Swazis eat five-a-day fruit and vegetables. Constipation and haemorrhoids are very common problems.
There does not seem to be the pressure on young women here to be a “size zero”. Plus size women can even get to the final stages of beauty pageants. Temphilo Princess Nxumalo, “a confident big lady”, almost won the title of Miss UNISWA (University of Swaziland).
One of my patients who suffers from both hypertension and diabetes has been dieting after we had warned her she was seriously overweight. When I saw her, she had lost 20kg, coming down from 132kg to 112kg. I congratulated her and said that she only had another 30kg to lose and she would move from “morbidly obese” to “overweight”. She looked at me in horror. “All my friends think I have HIV because I have lost this weight. They think I am ill. No one believes me when I say I am losing weight for the good of my health,” she said. “I have lost enough weight now. I am happy with this size.”
Another middle-aged lady, who looked pleasantly plump, told me she was worried about her weight. I measured her and said that her Body Mass Index was 27, meaning overweight, but not excessively so. I advised her that she was close to a healthy weight and would not have to lose much. “Lose weight, dokotela?” she exclaimed. “I need to put weight on. All my friends think I am too skinny.”
Swaziland has one of the highest rates of type 2 diabetes in Africa. About 5% of the population are affected. Swazi women tend to be pear shaped and carry a lot of additional weight in their backsides. I remember reading about this racial characteristic in an anatomy book at medical school. It was termed “Bantu buttocks”.
One obese lady consulted me about lower back pain. Via my translator, I asked her if the pain went into her buttocks. My translator looked at me over the top of her glasses and said, “Doctor Ian, you should not use that word. It is not polite.”
“But what should I call this area? I can’t think of any nicer term,” I said.
“It is our natural African beauty,” she replied. I misheard her and said, “Her booty? That’s what Beyoncé has. I believe they call it junk in the trunk.”
“Eh doctor, you can be very naughty at times,” she replied.
A friend, Emeritus Professor of Nutrition at King’s College London, Tom Sanders, told me that the cause of obesity is likely to be consumption of large portion sizes of starchy food, rather than drinking excessive amounts of sugar-laden fizzy drinks or eating Western-style food.
I see very few malnourished children in our urban clinic at Matsapha. Those that are invariably suffer from tuberculosis and/or HIV infection. But I do see some grim dental caries in well-fed children.
For many older obese patients, going to the gym to exercise is not an option. They would need a car to get there. Few people want to walk, most use Kombis, but many aspire to owning a motor. There are more than a dozen second hand car lots in Manzini. Some specialise in importing pre-owned vehicles from Japan. The cars at the front of the lots tend to be more desirable German saloons from Mercedes and BMW.
Lots of people want to drive their own car, but before they do so, they have to pass their driving test. There are several driving schools in town, but one caught my eye recently. The sign on the roof of the small car said “Leaner Driver”. It could have been a typographical error, or perhaps fatter people really do need to learn to drive in bigger cars. Sadly, I could not get my camera out in time to capture the moment.,
Googling this, I found Lombhindza Driving School, “Instruct leaner for defensive driving skills… also help foreign people to change into Swazi driving laws. They have branches in Manzini.”
Every week the local newspaper names and shames those drivers who have been caught and punished for driving while under the influence of alcohol. I was amused by the story of one driver who was almost three times over the limit when stopped by the police. His excuse was that he was normally a cider drinker, but his friends had given him whisky instead. The magistrate told him to thank his ancestors “because they worked under crisis” (trying to keep him out of trouble).
Another driver had failed to stop when instructed to do so by the police. He had compounded his crime by speeding away, failing to stop at a red traffic light and a stop sign. He pleaded guilty but in mitigation, he said was that he was rushing home to his children as it was his turn to babysit and cook for them. His wife had gone out to a church service on Good Friday.
The magistrate said, “If your wife makes you cook, take her to SWAGAA (Swaziland Action Group Against Abuse) for abusing you. It is her responsibility to cook at home.” He still found him guilty and sentenced him to pay either $200 or spend two years five months in jail.