New Obesity Boom In Arab Countries Has Old Ancestry
Jidat Mint Ethmane grew up in a nomad family in this impoverished nation in the western Sahara. When she was 8, she says, her mother began to force-feed her. Ms. Ethmane says she was required to consume a gallon of milk in the morning, plus couscous. She ate milk and porridge for lunch. She was awoken at midnight and given several more pints of milk, followed by a pre-breakfast feeding at 6 a.m.
If she threw up, she says, her mother forced her to eat the vomit. Stretch marks appeared on her body and the skin on her upper arms and thighs tore under the pressure. If she balked at the feedings, her mother would squeeze her toes between two wooden sticks until the pain was unbearable. "I would devour as much as possible," says Ms. Ethmane. "I resembled a mattress."
Today, Ms. Ethmane, 38 years old, is slender because her family ran out of money to continue the force-feeding technique, known as gavage. The term stems from the French word for the process used to force-feed geese to make foie gras. Yet in a recent interview in her family's one-room house, Ms. Ethmane says she still believes in the practice. "Beauty is more important than health," she says. Her husband, Brahim, agrees: "It is thin women who are not healthy."
The belief that rotund women are more desirable as wives helps explain why much of the Arab world -- which stretches from the Persian Gulf in the east to Mauritania in North Africa -- is experiencing an explosion of obesity. About half of women in the Middle East are overweight or obese, according to the United Nations' World Health Organization. In some communities, many of which were nomadic until a few decades ago, oil wealth has dramatically improved living standards. The resulting urbanization has introduced some Western habits: high consumption of sugar, fat and processed foods and more sedentary lifestyles.
In Bahrain, 83% of women are obese or overweight, according to International Obesity Task Force, a London-based think tank that tries to persuade countries to tackle the problem. In the United Arab Emirates the figure is 74%; in Lebanon it is 75%, the groups says. By comparison, about 62% of American women are overweight or obese. The prevalence of childhood obesity in the Middle East has risen rapidly in recent years and diabetes is spreading across the region, according to WHO.
Even predominantly Arab North African countries without oil wealth are wrestling with the challenge, in part because of a traditional preference for larger women. Half of all women in Tunisia and Morocco are overweight or obese -- two standard measures of a person's weight -- according to a 2001 study published in the U.S.-based Journal of Nutrition.
"We thought obesity was restricted to resource-rich countries, but it's also being reported in poor stratas," says Kunal Bagchi, a Cairo-based nutrition expert for WHO.
Mauritania is the only nation today where force-feeding of girls is systematically practiced, mostly in rural areas. Efforts by women's groups and the government to stamp it out have largely been ignored. In a land that suffers from a constant shortage of food, plump women are assumed to be both wealthy and more likely to bear healthy children. "It has long been totally acceptable for women to be not just rotund, but voluminous," says Philip James, chairman of the International Obesity Task Force.
After years of not acknowledging the health problems associated with obesity, Arab governments are now growing concerned about their financial impact. Obesity and associated illnesses, such as diabetes, account for an increasingly large share of the Middle East's total health costs, according to the International Obesity Task Force.
In early December, representatives from WHO, the U.N.'s Food and Agricultural Organization and about 20 Middle Eastern and North African states met in Cairo for the first time to develop dietary guidelines that take into consideration local eating habits. One nutritionist noted than an anti-obesity plan would have to take into account the region's preference for rotund women, according to Jaffar Hussain, a Cairo-based WHO medical officer, who attended the meeting. He says country representatives decided to study the issue and report back in at least six months.
In few places is the clash between culture and health more pressing than in Mauritania, a predominantly Arab nation of three million people. Mauritania borders Algeria, Mali, Senegal and Western Sahara and is roughly the size of France, from which it won independence in 1960. Today the country is a closed society ruled by an authoritarian Islamic government.
Gavage in Mauritania originated decades ago at a time when many prosperous families kept slaves. Back then, men stayed lean through working while women led more sedentary lifestyles. Faced with life in a harsh desert landscape, men typically sang songs not about the beauty of nature, but the attractiveness of the large women who might bear them healthy children.
Force-feeding is usually done by girls' mothers or grandmothers; men play little direct role. The girls' bellies are sometimes vigorously massaged in order to loosen the skin and make it easier to consume even greater quantities of food.
The practice of gavage has survived even though, since the 1970s, Mauritania has suffered prolonged droughts that have led to food shortages. That situation could worsen. Earlier this year, locusts invaded Mauritania in swarms up to 25 miles long, ravaging its crops and pasture land.
There are no current data about gavage, in part because the country's isolation makes it a difficult study for international health agencies. A 2001 government survey conducted by Measure DHS, a research firm in Calverton, Md., estimated that about 22% of Mauritanian women were force-fed as young girls. Half of those girls became overweight or obese as adults and many suffer from diabetes, heart disease and gastric ailments, the survey says. Local officials say some women are so fat they can barely move.
In the survey of 7,000 adults, 15% of the women said their skin split as a result of overeating. One-fifth of women said their toes or fingers were broken to make them eat. One-third said they regretted they had been subjected to overeating. Most cited the health consequences, the difficulty of walking and the pain they endured while being force-fed. A small number said their excess weight had made childbearing more difficult.
Charlotte Abaka, a Ghanaian advocate for women's rights in Africa, says gavage also encourages women to marry young because their rapid weight gain makes them appear older.
Even in the capital city, away from the rural areas where the practice is most prevalent, many Mauritanian women appear stout. Women wear a loose wrap-around dress, known as a mehlafa, which makes it difficult to see the outlines of their bodies. But their discomfort is obvious; many struggle to keep up with their husbands. Most men in Mauritania are slim.
Neya Mint Ally was force-fed for five years as a young girl. Now, 36 years old, Ms. Ally is about 5 feet tall and weighs more than 160 pounds. She finds it difficult to walk and suffers from gastric problems. "It was painful," recalls Ms. Ally. "But as a child I wanted to be fat to be beautiful."
One year ago, Ms. Ally founded a volunteer organization to help stamp out the practice and traveled to remote areas to publicize the health consequences of being overweight. Another group, the Mauritanian Association for Women's Promotion, known by its French acronym, AMPF, shows videos about gavage-related health problems in nine youth centers around Nouakchott. About four years ago, the Mauritanian government, alerted to the health risks of gavage, launched a radio and television campaign to put an end to it.
The anti-gavage campaign has been slow going, in part because about 65% of Mauritanian women are illiterate. That can stymie educational efforts. "If we encourage girls to go to school they will realize that gavage isn't good for them," says Mariem Bint Ahmed Aicha, who became the country's first female minister in the early 1990s when she was put in charge of women's affairs. She also sits on the ruling party's executive committee and is the founder and president of AMPF.
Wanton overeating has virtually disappeared among Mauritania's educated classes, Ms. Aicha says. Ms. Aicha's mother tried to get her to put on weight when she was young, but was overruled by her father, a teacher.
Ms. Aicha's daughter, a 19-year-old law student and mother of a 2-year-old baby, is slender even by Western standards. She says exposure to Western TV shows and magazines convinced her it's healthier to maintain a middling weight. "I don't want to be too fat, but I don't want to be too thin either," she says.
Other changes are more subtle. "Nowadays, many parents don't use physical force as much as psychological force to get their daughters to gain weight," says Ahmed Ould Isselmou, chief of the Mauritanian Department of Social and Demographic Statistics, a government agency. He helped design the government's 2001 survey. Ms. Isselmou adds that some girls now make a personal choice to overeat because they think it increases their chances of finding a husband.
Ms. Ethmane, who grew up in the nomad family, says her family is too poor to force-feed their three daughters. She had considered sending their oldest daughter, Mariam, to a relative who would force-feed the girl for a fee, but the family couldn't raise the money. Mariam, a slender 19-year-old, regrets her parents' decision not to fatten her up. "My friends went through this process," she said. "Now I don't like hanging out with them because I'm too thin."
One recent night, at the Pharmacy of Everlasting Beauty in downtown Nouakchott, the owner displayed four popular drugs that are sold as appetite enhancers. The most expensive, sold under the brand name Tres Orix, was priced at a hefty 2,070 ougyuia, the equivalent of about $8. The annual per capita gross domestic product in Mauritania is about $1,800. Nonetheless, business in the drugs is brisk. "It's mainly women who buy them," said the pharmacist. "They're very popular."
Oum Kelthoum Mint Mohammed, who lives on the outskirts of Nouakchott, was a lithe 13-year-old when she got married in 1999. She says her parents had previously tried to make her overeat but she rebelled and they didn't force her. "I couldn't see any reason to be fat," she said.
But months after her wedding, Ms. Mohammed began to eat voraciously, worried her new husband might leave her for a chubbier woman. She didn't own a set of scales and frequently visited shops in the city center to check her weight. Her husband, who doesn't have a preference for stout women, objected to her new regimen.
Recently, Ms. Mohammed weighed in at about 200 pounds. Her bones hurt and she found it increasingly painful to move or walk. To alleviate her pain, she has since set herself a new weight goal: 190 pounds. "I've eaten enough," she says. "Now I'm on a diet."
阿拉伯妇女以胖为美烦恼多
吉达?明特?爱斯梅恩(Jidat Mint Ethmane)在毛利塔尼亚一个游牧家庭中长大。她说，在8岁的时候母亲就强行给她喂食。早晨，她要喝一加仑的牛奶，加上蒸粗麦粉；中午喝牛奶和麦片粥；半夜她还会被叫醒来喝几品脱的牛奶；早晨6点，在早餐之前还要吃一次。
她说，如果她吐出来了，母亲就会强迫她把吐出来的东西吃回去。她身上因为肥胖出现了白纹，上手臂和大腿的皮肤都被撑裂了。如果她不愿意再吃，母亲就会用两根木棍夹她的脚趾，直到她无法忍受。“我尽可能多地往肚子里吞东西，”爱斯梅恩说，“我胖得就像一个床垫。”
现在38岁的爱斯梅恩变得苗条了，因为后来家里没有钱再进行这种称为“填食”(gavage)的喂养方法了。这个词源自法语，原来指的是强行给鹅喂食，以获得肥鹅肝。然而最近在爱斯梅恩家进行的一次访谈中，她表示仍然相信这种做法。“美丽比健康重要，”她说。她的丈夫布雷姆(Brahim)也同意她的观点：“瘦的女人才不健康呢。”
阿拉伯人认为胖女人更适合做妻子。这种观念可以解释为什么从波斯湾到北非毛利塔尼亚的阿拉伯世界，胖人的数目在急剧攀升。根据联合国世界卫生组织(World Health Organization)的统计，大概有一半的中东女性超重或肥胖。在一些直到近几十年前还是游牧民族的国家，石油财富大大改善了他们的生活水准。随之而来的城市化也带来了西方的生活习惯：人们大量摄入糖、脂肪和加工食品，并且更加疏于运动。
根据伦敦智囊机构国际肥胖工作小组(International Obesity Task Force)的报告，在巴林，83%的女性体重超重或肥胖。在阿拉伯联合酋长国，这一比例为74%，黎巴嫩为75%。相比之下，美国超重或肥胖的女性只有62%。根据WHO的统计，近几年，中东国家的肥胖儿童数目增长迅速，糖尿病在该地区快速蔓延。
甚至连没有石油财富的北非阿拉伯国家也在与肥胖问题作斗争，部分原因在于人们偏好肥胖型女性。根据美国《营养学杂志》(Journal of Nutrition) 2001年的一份研究报告，突尼斯和摩洛哥有一半的女性超重或肥胖。超重和肥胖是衡量体重的两个标准。
“我们以为只是资源丰富的国家才有肥胖症的问题，现在有报告称一些穷人中也有类似情况，”WHO驻开罗的营养专家库纳尔?巴格奇(Kunal Bagchi)说。
毛利塔尼亚是当今唯一一个保持给女孩强行喂食传统的国家，其中多数是在乡村地区。一些女性团体和政府努力让人们抛弃该传统，但大多无效。在这个长期饱受食物短缺之苦的国度，人们认为丰满的女性健康，且养育的孩子也健康。“一直以来，人们都十分接受这种观点：女人不仅要丰满，甚至要肥壮，”国际肥胖工作小组主席菲力浦?詹姆斯(Philip James)说。
阿拉伯国家政府多年来一直忽视肥胖带来的健康问题，如今也越来越关注这个问题对财政经济的影响。据国际肥胖工作小组称，肥胖及其引起的疾病（如糖尿病）占中东国家卫生健康支出的比重越来越大。
12月初，世界卫生组织代表、联合国粮农组织(Food and Agricultural Organization)和大约20个中东和北非国家代表首次在开罗碰面，讨论如何制定照顾到当地习惯的饮食指导方针。据与会的世界卫生组织开罗医疗官员贾伐尔?侯赛因(Jaffar Hussain)称，会上一位营养专家指出，抵制肥胖的计划应该考虑到当地人对丰满女性的审美偏好。他说，国家代表们决定研究这个问题并最快在6个月内回馈。
也许很少有别的国家在文化与健康方面的冲突像在毛利塔尼亚那么厉害。这个以阿拉伯人为主的国家有300万人口，与阿尔及利亚、马里、塞内加尔及西撒哈拉接壤，面积与法国差不多，1960年原是法国殖民地的毛利塔尼亚获得独立。这个封闭的国家至今仍由伊斯兰政府统治。
“填食”在毛利塔尼亚开始于几十年前。那个年代，许多富裕的家族都有奴隶。那时，男性由于劳动而体形偏瘦，而女性则不怎么活动。艰苦的沙漠生活使得男人们歌颂的不是大自然的美妙，而是丰满女人的诱惑，因为她们能养育健康的孩子。
一般都是母亲或祖母给女孩强制喂食，男人们几乎不直接参与。有时家长会使劲儿按摩女孩的腹部，使皮肤松弛，以便能装下更多的食物。
自70年代以来，尽管毛利塔尼亚遭受了长时期的乾旱，食物短缺，但填食的做法仍然被保留了下来。旱情甚至还可能恶化。今年初，大批蝗虫袭击了毛利塔尼亚，绵延达25英里，大面积的庄稼和草原被毁。
目前还没有关于填食的最新资料，部分由于这个国家的封闭使得国际卫生机构很难开展研究。2001年由马里兰州Calverton研究机构Measure DHS做的一份政府调查报告估计，有22%的毛利塔尼妇女在幼年时都被家长强行喂食。调查称，这些女孩成年后有一半身体超重或肥胖，很多妇女倍受糖尿病、心脏病和各种胃疾的折磨。地方官员称，有些妇女太胖以至行动困难。
这个调查访问了7,000名成年妇女，15%的被访者说食量过度导致皮肤裂开；1/5的妇女表示在被强迫进食时脚趾和手指曾被弄伤；1/3的妇女对被迫过度进食表示后悔。大部分人都提到过度进食给健康带来的后果、行走上的困难和被迫进食时的痛苦。有小部分人表示超重使得生育更加困难。
非洲女权宣导者、加纳人夏洛特?阿巴卡(Charlotte Abaka)称，填食促使女性很年轻就结婚，因为迅速增胖使得他们看起来年龄较大。
甚至在离盛行这种习俗的乡村很远的首都，填食也很流行，很多毛利塔尼妇女身材都很粗壮。这里的妇女们都穿一种叫“mehlafa”的宽松裹布裙，不容易看清身体轮廓。但肥胖带给她们的不便显而易见，很多妇女走路时要很费劲才跟得上她们的丈夫。大多数毛利塔尼男人都较瘦。
内娅?明特?阿里(Neya Mint Ally)年幼时被强行喂食了5年，现在36岁的她高5英尺，体重超过160磅。她行走困难，有胃疾。“很痛苦，”阿里回忆道。“但小时候我想变胖，为了好看。”
一年前，阿里成立了一个旨在帮助人们抛弃填食做法的志愿者机构，到边远的地区宣传身体过胖对健康的害处。另一个机构“毛利塔尼亚妇女促进协会” (Mauritanian Association for Women's Promotion, 法语缩写：AMPF)在首都努瓦克肖特的9个青年中心播放录像，讲述有关填食引起的健康问题。大概4年前，毛利塔尼亚政府开始警觉到填食带来的健康危机，在电视和电台开展了一场摒弃这个不良习俗的宣传运动。
反填食运动进展缓慢，部分原因在于65%的毛利塔尼亚妇女是文盲，教育宣传大受阻碍。“如果我们鼓励女孩们上学，她们会意识到填食对她们是不好的，”玛丽恩姆?宾特?阿麦德?艾查(Mariem Bint Ahmed Aicha)说。她在90年代初成为毛利塔尼亚第一位女部长，负责妇女事务。她还是执政党执行委员会成员，AMPF的创建者兼主席。
艾查称，过度进食的做法在毛利塔尼亚受教育阶层中几乎已经消失。她小的时候，母亲也试图让她增胖，但被当教师的父亲制止了。
艾查的女儿19岁，是法律系学生，有个2岁的孩子。甚至用西方标准来看她也是很苗条的。她说接触西方电视和杂志使她明白保持适中的体重更健康。“我不想太胖，但也不想太瘦，”她说。
还有其他一些更微妙的变化。“如今，很多家长用心理战术而非行动促使女孩们增肥，”毛利塔尼亚社会人口统计部负责人阿麦德?乌尔德?艾泽默(Ahmed Ould Isselmou)说。艾泽默参与设计了政府2001年的调查。艾泽默还说，现在有些女孩自己选择增肥，因为她们觉得这样更容易找到丈夫。
在游牧家庭长大的爱斯梅恩说她的家庭太拮据，无法给三个女儿强行进食。她曾经考虑过把最大的女儿玛丽安姆(Mariam)送到一个亲戚那儿，这位亲戚将负责给她强行喂食，并收取一定的费用，不过爱斯梅恩一家还是没办法筹到钱。现在19岁的玛丽安姆很苗条，对父母没让自己变胖感到遗憾。“我的朋友都经历了强食的过程，”她说,“我现在不想跟她们一起玩，因为我太瘦了。”
最近一个夜晚，在努瓦克肖特市中心的Pharmacy of Everlasting Beauty药店，店主摆出了4种颇受欢迎的开胃药。一种牌子为Tres Orix的开胃药卖得最贵，要2,070乌吉亚，大概相当于8美元。毛利塔尼亚每年的人均国内生产总值在1,800美元左右。然而这类开胃药的销售却十分强劲，“主要是女性购买，”店主说，“这些药很受欢迎。”
乌姆?凯尔道姆?明特?穆罕默德(Oum Kelthoum Mint Mohammed)生活在努瓦克肖特的郊区，1999年结婚时只有13岁。她说之前父母曾让她吃很多，但由于遭到她的反抗就不再强迫。“我觉得没有什么理由要变胖，”她说。
但结婚后几个月，穆罕默德开始大吃特吃，因为担心新婚丈夫离开她去找一个丰满的女人。她那时没有体重秤，所以经常到市中心的商店去量体重。她的丈夫也不是特别喜欢丰满女性，对她的做法并不赞同。
最近，穆罕默德体重达到了200磅左右。她发现走路和行动时骨头越来越疼。为了缓解疼痛，她给自己定了一个新的体重目标：190磅。“我已经吃得够多了，”她说,“现在我要节食了。”
