The children of Bees Haven kindergarten are about 15 minutes into their weekly taekwondo class when their instructor has some stern words for them. “You guys are not panting,” says Lizzanne Adhiambo, with a grin. “I want to see the power! Let’s punch!”
Aside from a certain amount of confusion over left and right hands, Adhiambo’s pupils obey. With alternating arms they punch out in front of them, 15 four- to six-year-olds, wearing white training uniforms , shouting “Yeah!” as the instructor counts from 1 to 10.
“They love it so much,” says Beryl Itindi, director of the pre-primary school in Syokimau, on the south-western outskirts of Nairobi.
After class, the children sit down for lunch of beef stew, leafy greens, ugali – maize flour porridge – and fresh fruit. “Thank you for our food and our many blessings,” they chorus. “Amen.”
These children are at the forefront of new efforts to foster lifelong habits of exercise and healthy eating – and stave off a foe increasingly visible in Kenya’s towns and cities: obesity.
As in much of Africa, the number of people classed as obese in Kenya is on the rise: by 2030, the World Obesity Atlas says 1.4 million five to 19-year-olds will be obese. The WHO considers a person with a body mass index (BMI) over 25 to be overweight, while a BMI over 30 is obese.
A 2015 survey – the most recent undertaken – found 20% of Kenyan men and more than 50% of women were either overweight or obese.
The human toll of non-communicable diseases (NCDs) is huge and rising. These illnesses end the lives of approximately 41 million of the 56 million people who die every year – and three quarters of them are in the developing world.
NCDs are simply that; unlike, say, a virus, you can’t catch them. Instead, they are caused by a combination of genetic, physiological, environmental and behavioural factors. The main types are cancers, chronic respiratory illnesses, diabetes and cardiovascular disease – heart attacks and stroke. Approximately 80% are preventable, and all are on the rise, spreading inexorably around the world as ageing populations and lifestyles pushed by economic growth and urbanisation make being unhealthy a global phenomenon.
NCDs, once seen as illnesses of the wealthy, now have a grip on the poor. Disease, disability and death are perfectly designed to create and widen inequality – and being poor makes it less likely you will be diagnosed accurately or treated.
Investment in tackling these common and chronic conditions that kill 71% of us is incredibly low, while the cost to families, economies and communities is staggeringly high.
In low-income countries NCDs – typically slow and debilitating illnesses – are seeing a fraction of the money needed being invested or donated. Attention remains focused on the threats from communicable diseases, yet cancer death rates have long sped past the death toll from malaria, TB and HIV/Aids combined.
'A common condition' is a new Guardian series reporting on NCDs in the developing world: their prevalence, the solutions, the causes and consequences, telling the stories of people living with these illnesses.
Tracy McVeigh, editor
In a report last year, Kenya’s government recognised obesity as a major risk factor for non-communicable diseases (NCDs) such as diabetes and cancer, which are responsible for 39% of deaths in Kenya – up from 27% in 2014.
“The statistics show that obesity is growing at a very alarming rate, not just in Kenya but in the region and world,” says Stephen Kimutai Tanui, strategy manager for Wellness for Greatness, the organisation behind the taekwondo classes.
The education the group is giving children was sorely lacking when Tanui, 32, was a child: “We were not told that physical activity has very many benefits … not just to enjoyment and performance in school but to our health.”
In a country stalked by hunger and where more than three million people are classed as acutely food insecure, the priority was getting enough food, irrespective of its nutritional value, he says.
“When we were young, that link between good nutrition and good health was missing,” says Tanui. “In Kenya and in most African countries we have a problem with malnutrition, and that’s what everyone focuses on. People should have food, but we should also focus on getting good and healthy foods, because the rates at which obesity is growing, they are going hand in hand: malnutrition and obesity. It’s a terrible burden.”
In parts of the rural north and east, the worst drought for 40 years is driving thousands of Kenyans from their homes. According to the International Federation of the Red Cross, approximately 755,000 children under five will be acutely malnourished throughout 2022.
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In Nairobi, where fast food chains such as KFC, Burger King and Domino’s stand on every other street corner, and billboards push “vitamin-enriched” chocolate drinks to motorists on the heaving roads, the problem is “completely different” says Dr Davis Ombui, a diabetologist. “People get to jobs in the morning, get into office, get back into their cars, go home. They don’t walk to work as much, and fast food is now a big thing in Nairobi.”
The result is clear at his private clinic surgeries. “We are seeing younger and younger people diagnosed at a younger age. Today I had someone who was 21 . Type 2 diabetes. It’s all because of obesity; all because of the lifestyle.”
Last year the ministry of health published a strategic plan to respond to its “epidemiological transition” in disease burden from communicable diseases, such as malaria and tuberculosis, to the rising burden of NCDs. It recognised obesity as a major risk factor, but doctors fear there is little concrete action.
“You might find these policies are there on paper,” says Ombui. “But no one is translating that into action on the ground. I’m sure if you go to the cabinet you’ll find really nice policy papers that were sponsored by WHO and [other] organisations – just gathering dust.”
The health ministry was approached for comment. The government’s target is to reduce obesity prevalence from 28% in 2020 to 26% in 2025, and the clock is ticking. By 2030, NCD deaths are expected to increase by 55%.
And there remains a lingering association in society between excess fat and material success.
“You find young people at university want to add weight and grow a belly as a status symbol. It’s that bad,” says Stephen Ogweno, CEO of Stowelink, a youth-led enterprise aimed at combating NCDs. “There is still this perception that needs to change.”
For well-off Kenyans, Dr Wyckliffe Kaisha has the answer. One of the few surgeons in the country to perform bariatric – or weight loss – surgery such as gastric bypasses, he has seen a significant increase in patients, partly due to Covid-19, which alerted more people to the ramifications of obesity, diabetes and hypertension.
One of his patients, a 29-year-old who last year had a sleeve gastrectomy – involving removing part of her stomach – has no regrets.
“It requires somebody to be psychologically and emotionally prepared because it is not easy, especially if you’re used to taking a lot of junk [food]. I really loved chips. Nowadays I can’t even stand the smell of fries,” she says.
The woman, who does not want her name published, says she has lost 40kg: “At least now I can walk up stairs. I don’t have to depend on lifts.”
Bariatric surgery has its critics, but Kaisha insists it is beneficial for the vast majority. His bugbear is with insurers, who refuse to cover the procedure, meaning only the wealthy can afford his $5,000 charges.
He has told insurers that bariatric surgery is cost-effective as it prevents conditions developing. “They still reject it and say it is cosmetic surgery. But it is not at all,” he says.
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The village of Njathaini, on the northern outskirts of Nairobi, is a world away from Kaisha’s clientele. With high unemployment and little disposable income, it is in places like this that intervention is urgent, says Ogweno.
Thanks to genetics, diet and lack of exercise, Ogweno, 26, once weighed almost 20st. Driven by wanting to “look like Dwayne ‘The Rock’ Johnson” he lost weight at university and competed in Mr Fitness contests.
He wants to prove that obesity, diabetes and cancer don’t just affect “the old and the rich.” What he and his colleagues found in Njathaini shocked them: “[This is] a very low-income community, and almost 70% of the homes here live with diabetes or hypertension,” says Ogweno, sitting in the village chief’s office.
Traditional diets in poor neighbourhoods rely heavily on carbohydrates and cooking fat with vertiginously high levels of transfats, known to increase the risk of heart disease. At one Njathaini shop, you can buy a cabbage for 70 shillings (50p). At another, a few doors down, there are bags of crisps for 20 shillings, and fried bread rolls are 10 shillings.
Then there’s the sugar. “Soft drinks are more available than clean water,” says Ogweno. The shops are fully stocked with fizzy drinks, and bunting advertising Sprite, Coca Cola and Fanta, as well as water, greets every customer.
Francis Njuguna, a community health worker, was born and bred in Njathaini. “Before, it [obesity] was a non-issue. There were very few cases. But nowadays there’s a lot of people,” he says.
Working with Stowelink, Njuguna advises local people on growing vegetables as well as other cash crops. “Kale, tomatoes, onions, spinach” are all possible, he says.
The worst aspect, says Ogweno, is that once people are diagnosed with conditions associated with obesity, they struggle to get treatment.
“If you’re not formally employed … you are almost always not covered [by national health insurance] and if you are sick you have to pay out of pocket,” he says. This applies, for instance, to insulin for diabetics. “People literally have to rally the whole village to contribute cash to then go and do that because otherwise it’s a death sentence.”
Ogweno, whose aunt died from diabetes after seeking help from a traditional healer, feels the government is moving, slowly and belatedly, to take NCDs seriously.
For the moment, then, it is the Bees Haven children forging the way. Exuberant after their training, the kindergarten’s martial artists eat their lunch enthusiastically – even the managu greens. Often the children arrive rather shy, says Itindi, the director, and the exercise “really opens them up both mentally and physically.”
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