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Keywords:

  • gender;
  • Morocco;
  • nutrition transition;
  • obesity

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. Data, methods and measures
  6. Main findings and discussion
  7. The impact of marital status
  8. The impact of age
  9. The impact of socioeconomic status
  10. Conclusion
  11. Acknowledgements
  12. References

Often referred to as the developing world's new burden of disease, obesity constitutes a major and growing health epidemic in Morocco, in particular for women (22% of women versus 8% of men). Through an analysis of qualitative data, I demonstrate how gender roles influence obesity risk in the Moroccan context. Current social and economic theories, including the nutrition transition theory, are inadequate in explaining the persistent gender differentials in health status across time and place. I suggest that Moroccan women's higher prevalence of obesity is predominantly the outcome of different risks acquired from their distinct roles. In the Moroccan context, we can gain insight into how men and women divide household labour and how the overall non-egalitarian nature of social roles may deleteriously affect women's health. I hypothesise that marital status, age and socioeconomic status determine Moroccan women's household roles and help to explain why women are more likely to be obese than men. The main findings support this hypothesis and demonstrate the interactive relationship between culture and structure in influencing obesity risk.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. Data, methods and measures
  6. Main findings and discussion
  7. The impact of marital status
  8. The impact of age
  9. The impact of socioeconomic status
  10. Conclusion
  11. Acknowledgements
  12. References

When researchers consider the nutritional problems of the developing world, obesity is not usually the first thing that comes to mind. Paradoxically, it is becoming increasingly clear that as developing countries continue their efforts to reduce hunger, some are also facing the opposite problem of obesity. Morocco is one such country experiencing this trend. Among Moroccan adults, obesity increased from four per cent in 1984 to 13.3 per cent in 2000. Of particular interest is that the prevalence of obesity continues to be significantly higher among women than among men in Morocco, and this gender difference in obesity prevalence continues over time. In 1984, 6.4 per cent of women and only 1.6 per cent of men were obese (Benjelloun 2002). By, 1998, 16 per cent of women and only 4.3 per cent of men were obese. The latest data for the year 2000 revealed that the numbers had increased to 22 per cent of women and eight per cent of men.

Here, I use female obesity as a lens through which to understand issues related to women's statuses and roles. In the Moroccan context, we can gain insight into how men and women divide household labour and how the overall non-egalitarian nature of social roles may deleteriously affect women's health. I suggest that gender differentials in health, and specifically Moroccan women's higher prevalence of obesity, are predominantly the outcome of different risks acquired from their distinct roles (Arber and Khlat 2002). I suggest that marital status, age and socioeconomic status (SES) are determinants of a woman's household roles in the Moroccan context and I hypothesise that they help us to understand why women are more likely to be obese. The main findings support this hypothesis by showing how gender roles determine the household activities performed by Moroccan women and thus might explain their increased likelihood of being obese as compared with Moroccan men.

Background

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. Data, methods and measures
  6. Main findings and discussion
  7. The impact of marital status
  8. The impact of age
  9. The impact of socioeconomic status
  10. Conclusion
  11. Acknowledgements
  12. References

The nutrition transition in Morocco

I will first discuss the prevalence of female obesity in Morocco in the context of the nutrition transition theory. The nutrition transition is distinguished by a shift from traditional diets high in grains, fruits and vegetables and low in fat to diets high in sugar, refined grains and fat (Drewnowski and Specter 2004, Monteiro et al. 2002). In the Moroccan context, the diet has changed considerably as a result of the socioeconomic transition: the intake of animal products has increased while that of cereals and sugar remained relatively high, reflecting the specificity of Moroccan dietary habits. In addition, the rise in the consumption of meats and vegetables has been accompanied by a steady consumption of bread, used to eat the sauce in which the meat and vegetables are cooked. This is all occurring in combination with the excessive all-day consumption of the national drink, mint tea – whose main ingredient is large amounts of sugar – as well as increased access to imported processed foods associated with high social status (i.e. McDonalds, Coca Cola).

According to the nutrition transition theory, increases in urbanisation promote a significantly more sedentary lifestyle, as both leisure and labour activities are replaced by more mechanised activities, such as television watching and non-agricultural labour (Brown 2001, King et al. 2001, Pasquet et al. 2003, Pearte, Gary and Brancati 2004, Sobngwi et al. 2004). In Morocco, the urban population has increased from 29 per cent in 1960 to 53 per cent in 1997 and, on average, 145 people out of 1000 own at least one television set. Both of these numbers are increasing rapidly (UNDP 2005).

Rapid urbanisation has also been observed to produce the coexistence of malnutrition and obesity based on studies in Brazil, Russia, China and the US (Doak et al. 2000, Wang et al. 2002, Monteiro et al. 2002, 2004). As such, food insecurity still exists in many countries, such as Morocco, experiencing rapid increases in obesity. Contrary to more developed countries, food choice in developing countries may remain limited, either because of market limitations or cost (Aguirre 1994, Gulliford et al. 2003). Relative to the rest of the African continent, however, Morocco has a low proportion of under-nourishment, a relatively high dietary energy supply (per capita kcals/day) and a ‘sufficient’ national food energy supply (FAO 2006). Consequently, according to the World Bank (1998), Morocco is considered among other countries not to be ‘highly food insecure’. However, this was not always the case. Historically, Morocco has experienced times of significant famine and starvation and this still occurs seasonally, as witnessed recently by droughts in Southern Morocco (Meyers 1981, Swearingen 1992). Thus, there might be an important generation effect on the relationship between food insecurity and obesity risk in Morocco. There is increasing evidence that malnutrition early in life is one additional risk factor for obesity and other chronic diseases in adulthood, as well as resulting in an increased risk of stunting (Barker 1992, Law et al. 1992, Osmani and Sen 2003, Phillips et al. 1994).

Nutrition transition theory does not consider the role that gender and other social, economic and cultural factors may play in influencing diet and physical activity patterns. That is, these macro-level processes may have differential effects on the diet and physical activity patterns of men and women. Moreover, some of the aforementioned unique aspects of the experience of less developed countries may also affect women differently from men. For example, girls may have been more likely to experience stunting due to son preference beliefs and practices. During periods of food shortage, girls and women may have been the first to experience the effects of malnutrition and undernutrition. The differential effects of such macro-level processes have yet to be incorporated into a framework of social, epidemiological, demographic, and economic change.

Nutrition transition theory, however, is inadequate in explaining the persistent gender differentials in obesity risk in Morocco. It does not suggest a clear mechanism through which this relationship may operate nor does it reflect the particular socio-cultural contexts in which these inequalities occur. I suggest, therefore, an alternative theoretical framework to explain the gender differential prevalence rates of obesity in Morocco that combines both role theory and empirical data from Morocco.

Role theory

My starting point is that lifestyle is a key factor in accounting for the rise of obesity rates, and gender differences in lifestyle provide one possible explanation for this obesity risk. Since women and men are exposed to different lifestyles, this differential ‘exposure’ affects their health. In this way, in a Durkheimian sense, obesity rates can be conceived as social facts that can be explained in terms of lifestyle changes. Yet, it is not enough to say that obesity is caused by changes in eating habits. Rather, the way people eat is interconnected to other aspects of how they conduct their lives and the related ‘power balances’ at play (Elias 1978, Crossley 2004). I examine these power balances by focusing on how men's and women's roles in the household determine their specific and different lifestyles. The primary mechanism through which the relationship between stratification and obesity operates is through the particular household roles men and women occupy in Morocco. Role theory helps us to understand the relationship between men's and women's household roles and their health.

Role theory suggests that social institutions are made up of roles into which individuals fit. This framework recognises that these roles are pre-existing rather than negotiated by the individual. However, it incorporates a functionalist approach to society when it describes the roles as being made up of institutionalised norms and values (Collins 1994). That is, individuals are assigned roles (role allocation) and socially expected behaviour patterns (socialisation) by others, and act in response to their perceptions of the expectations that others, especially significant others, hold for them (Biddle and Thomas 1966).

Aspects of Nathanson and Schoen's (1993) theory of bargaining can be applied to the exchanges that occur across different Moroccan households. Their theory argues that women seek economic security and social status. In Morocco, this is most often achieved when a woman exchanges her domestic services and childbearing ability for her husband's financial support. According to this theory, other strategies may be employed based on the normative setting in which this exchange is occurring. In the Moroccan context, there is a clear set of rewards and sanctions for the particular strategy a woman selects in order to secure financial security. One common strategy for women in Morocco is to accept normative roles and their corresponding activities, such as those associated with religious rituals. Women are often motivated to conform to these roles because of both the set of rewards associated with the fulfilment of expected roles and the consequences of rejecting these roles.

Role theory has been extensively criticised for its overly functionalist basis and its lack of considering agency. In a recent study of women's health in mid-life McMunn, Bartley and Kuh (2006) draw on Giddens's (1984) theory of structuration and Doyal and Gough's (1991) theory of human needs to develop a theory of role quality based on the concept of agency. Giddens suggests that human agency and social structure are in a relationship with each other, and it is from the repetition of the acts of individuals that the structure is reproduced. According to Giddens, however, social structures such as traditions, institutions, moral codes, and established ways of doing things can be renegotiated when individuals replace them, ignore them or reproduce them in different ways. Yet, if the individual does not have what Doyal and Gough term ‘the autonomy of agency’ then these structures will be maintained. Following their work, I suggest that in the context of Morocco it is also important to consider the relationship between social roles and women's agency. That is, patriarchal structures (i.e. norms, traditions) limit the autonomy women have to choose their social roles and it might be this lack of agency that also contributes to the relationship between social roles and health, and not solely the deleterious health effect of the activities associated with the particular role. For example, it is well established that women in certain societies are often not in a position to choose or even prioritise work over family (Merton 1957, Moore and Gobi 1995, Izraeli 1993). Indeed, what follows, is that in most societies the work of caring for the family and doing domestic work falls to women – or is at least considered a woman's domain – while work outside the home is usually considered the domain of men (Lehrer and Stokes 1985, Marini and Brinton 1984).

It is well established that the social roles men and women occupy may account for gender differences in mental health (Sachs-Ericsson and Ciarlo 2000, Gore and Mangione 1983, Simon 1995), but obesity has only recently begun to be examined in this light (McMunn et al. 2006). Several theoretical frameworks describe the particular relationship between roles and health: women are thought to have poorer experiences within any given role (role strain theory), have more conflicts among their different roles (role-configuration theory), or benefit from multiple roles (health enhancement hypothesis) compared to men (Gove 1972, 1978).

The importance of household labour for women's health has already been noted in several studies (Bartley et al. 1992, Annandale and Hunt 1993). No study, however, has tried to explain gender differences in health through gender differences in household labour (Lennon and Rosenfeld 1992, Artazcoz et al. 2001, Borrell et al. 2004). In the Moroccan context, women's household roles, including childrearing and domestic chores (cleaning and food preparation), do not leave women with much leisure time to participate in exercise. Men, however, are more likely to participate in exercise than women because their household roles do not limit their leisure time. In addition, because food preparation is an integral part of women's household roles, women often eat snacks between meals thus increasing their overall daily caloric intake. Furthermore, during meals women tend to eat less nutritious, higher caloric foods than men because they tend to eat last. This is because of logistical reasons (i.e. they are busy serving the men) and ideological reasons (i.e. men are supposed to eat first because they are more socially and economically valuable).

Determinants of women's household roles in Morocco

Based on role theory and qualitative research in Morocco, I conceptualise marital status, age and socioeconomic status to be determinants of women's household roles in the Moroccan context.

It is important to recognise that women's roles in Morocco have changed over time both inside and outside the household. For example, recent reforms to the Moroccan family code (Mudawana) in 2004, which aimed to empower women, suggest interesting questions about how changes in women's status may affect their role in society (Sadiqi and Ennaji 2006). Moroccan women are increasingly participating in the paid labour market, delaying marriage and having fewer children (Assaad and Zouari 2003). The nature of their household roles has become somewhat less energy exerting with greater access to modern conveniences and technology, such as running water and refrigerators. However, it is difficult to quantify the effects of these changes on women's health because not all Moroccan women have equal access both to employment and technology. Similarly, there is tremendous diversity among Moroccan women in terms of their role preferences (Davis 1983).

Marital status

It is generally accepted that, overall, the married are in better health than the unmarried, because marriage has beneficial effects on health (marriage protection effects) and/or because healthier individuals are more likely to marry and to stay married (marriage selection effects) (Ross, Mirowsky and Goldsteen, 1990, Waldron, Hughes and Brooks 1996). However, the relationship between marital status and obesity is not well established (Sobal, Rauschenbach and Frongillo 2003). For example, a study examining the effect of ethnicity on weight gain in the United States found that married people weighed more than the unmarried (Sobal and Devine 1997). More specifically, they found that women tended to change weight more in that first year of marriage than men did. They point out, however, that other studies have shown that during the first two years of marriage, husbands and wives tended to exercise less and eat more but only husbands gained weight. Married men in these studies were found to have a higher BMI and to be more likely to be obese than never married or previously married men. These differences, however, do not emerge during the first year of marriage.

Similarly, another study in Poland found that in general married men and women were more likely to be overweight and obese than never married individuals (Lipowicz, Gronkiewicz and Malina 2002). The results indicated a significant association between marital status and BMI in both sexes. In fact, after age, marital status was the most important predictor of overweight/obesity among men in this study (Lipowicz, Gronkiewicz and Malina 2002). A Bahraini study on the prevalence of obesity and the demographic factors associated with it found that marriage was positively associated with obesity among women (al-Mannai et al. 1996).

Marriage is a particularly salient institution in Moroccan society (Kapchan 1996, Mernissi 1975). Families often spend a significant portion of their savings and monthly income on a wedding and may even invest in their daughter so as to improve her marriage potential. For many a woman, becoming a wife is the most important role that she and her family strive for throughout a woman's life in Morocco (Mernissi 1975). Even starting at an early age, parents take into consideration the consequences that certain decisions may have on their daughter's potential for marriage, such as her education and employment opportunities. For example, working as a maid in a household may decrease her potential for marriage.

Following marriage and becoming a wife, the next role most women work towards is becoming a mother as soon as possible after marriage. This role can be thought of as the ‘gateway’ to all other marital roles. While some women are able to fulfill this marital role rapidly and to acquire their corresponding rewards, others are not as successful and suffer the consequences, which may include divorce and tension in the household. In addition, there are certain activities associated with the role of daughter-in-law, such as performing the heavy household labour and any other chores requested by one's mother-in-law, such as preparing food involved with religious rituals. Although not as significant within the early years of marriage, the lifestyle associated with marriage may contribute to a woman's increased obesity risk over the lifecourse.

The accumulation of traditional roles, the most significant being the role of wife, contributes to a woman's obesity risk for several reasons. First, the expected activities associated with the role of a wife are located exclusively in the household and are often centred on food preparation. Secondly, prior to marriage, a woman may have more leisure time to participate in physical activity or other beneficial health activities. Thirdly, a single woman is not likely to have given birth which removes the possibility of weight gain associated with pregnancy. Fourthly, marriage and obesity risk are both associated with increased age; therefore, single women are often younger and are less likely to be obese.

Age

In the Moroccan context, age generally determines one's status within the household and how tasks are allocated (Moghadam 1995). Younger household members, particularly women, often perform the most energy exerting domestic chores. For example, a pattern can be observed in which daughters-in-law, along with the other younger female household members, perform the majority of heavy domestic tasks and older women have more sedentary responsibilities such as child care. In addition, women gain household status through their increased age. As a result, older women usually eat at the same time as the men. They thus consume higher quality food (i.e. more protein).

As discussed above, women accumulate a variety of roles over the lifecourse. Later in life, women are faced with another status-changing role; mother-in-law. Becoming a mother-in-law has important consequences and possible challenges. For example, when a mother becomes a mother-in-law her sphere of authority widens significantly, and her household roles change and become less energy exerting. For example in terms of religious ritual, the mother-in-law may be given the honour of pouring the tea for guests, but she would no longer be responsible for its preparation. In this same fashion, her contribution to domestic work becomes primarily supervisory. For example, a mother-in-law is likely to delegate some or all of the heavy workload to her daughter-in-law, such as cleaning the home. In exchange for her daughter-in-law's domestic labour, a mother-in-law may assume some of the responsibility for taking care of the children in the household (Lane and Meleis 1991).

Socioeconomic status

The ordering of household roles by age and marital status may be moderated according to a household's particular economic situation. Morocco can be characterised as having a sizeable unequal distribution of wealth such that there is a large (and, indeed, growing) gap between the rich and poor. Although a significant middle class is beginning to emerge in the major cities (i.e. Casablanca and Rabat), where industry and employment are most abundant, there remains a sharp and significant economic disparity between the highest and lowest economic classes (White 2001).

I suggest that cultural beliefs (i.e. certain ideas of beauty and space) and cultural practices (i.e. non-egalitarian divisions of household labour and particular rituals of hospitality) may foster certain household roles associated with increased obesity risk. The effects of these cultural beliefs and practices may be moderated by several socioeconomic co-variates, such as education, income and material lifestyle.

First, education may interact with the effects of cultural beliefs and practices on health. More specifically, high levels of education may reduce the effect of these beliefs and practices on a woman's likelihood of participating in obesity risk behaviour. Women with high levels of education may have access to information regarding the negative effects of obesity risk behaviours. In addition, education may allow women to participate in the labour force and thus be exposed to alternative health knowledge.

Secondly, income may interact with the effects of cultural beliefs and practices on health. Most importantly, women from high income households may have the financial ability to choose the foods they consume. Depending on income, households may be forced to allocate food resources based on a household member's economic contribution and thus may or may not practise gender segregated eating patterns. The Nutrition Efficiency Wage Hypothesis suggests that there is a nonlinear link between health and productivity and that the function is convex at very low levels of health (Strauss and Thomas 1998). That is, there may be some people who are so poor and so unhealthy that they are too costly to be employed. People in better health (higher BMI) are more likely to undertake strenuous tasks (Pitt, Rosenzweig and Hassan 1990). Similarly, this model predicts that poor households will allocate health resources unequally among members to ensure that at least one member is fit to work. This is less likely to occur in higher-income households.

Thirdly, in the Moroccan context, different social classes have particular material lifestyles associated with obesity risk behaviour. This assertion reflects Bourdieu (1984) who suggests that different classes think differently in relation to food, activity and the body, such that some groups are more prone to obesity than others. In fact, Williams (1995) has argued that we can observe Bourdieu's theoretical ideas on the class-based nature of ‘relations to the body’ in empirical data on health-related matters.

For example, higher social classes in Morocco almost always have domestic help. The presence of maids may change the nature of a woman's household role, as her responsibilities may no longer consist of domestic chores, such as food preparation and cleaning. More directly, domestic help physically reduces female household members’ burden of household chores, as well as the physical exertion accompanying these chores. In addition, higher income households may also own appliances, such as washing machines and dishwashers, resulting in the reduction of the physical exertion required for household activities. Living in a home with running water (thus avoiding the physical labour and time associated with fetching water from a well) and owning a refrigerator (thus making food preparation more efficient because food can be saved for future meals and shopping can be done less frequently) will similarly reduce the physical labour associated with domestic chores.

Women with access to these material goods might have increased leisure time. The activities that occupy this ‘leisure time’ are also dependent on social class. For example, women of the highest social classes may have been exposed to gyms and Western ideas of beauty whereas women of a lower social class may associate obesity as a symbol of affluence and may occupy their often-limited leisure time with what they conceive as high-status behaviour, such as watching television. As a symbol of status, as well as through the ability to afford the financial costs associated with exercise, high social class women may be more able to participate in exercise. In addition, because of their higher levels of education and exposure to preventive medicine these women may hold a certain knowledge regarding the etiology of obesity. These women may abstain and/or participate in certain adverse obesity risk behaviours, such as particular diets and physical activity patterns.

Women of high social classes may also hold body image ideals more congruent with ideas of beauty in the West that overwhelmingly value slender women. Following these ideas of beauty, women may alter their diet, physical activity and even dress patterns (i.e. whether to wear the traditional djelaba, a loose, non-form-fitting dress). Body image has been identified as closely related to social class. Higher social classes have been found to be associated with greater body dissatisfaction and slimmer body image ideals across diverse cultural settings, including Canada, the US, India and Egypt (McLaren and Kuh 2004, Jackson, Rashid and Saad-Eldin 2003, McLaren and Gauvin 2002, Chugh and Puri 2001). As noted, body image is not a static construct: it is dynamic and changes as women encounter changes in socioeconomic status at both the individual and household levels. In combination with other measures of material lifestyle, body image helps to elucidate how socioeconomic class affects obesity risk through the household roles it creates for men and women.

Middle class women, therefore, were hypothesised to be at the greatest risk of obesity because they neither participate in energy-exerting household labour nor do they access gyms and other alternative sources of exposure (i.e. particular media images) that might encourage a slim body image ideal. In sum, cultural contexts and structural variables do not exist in separate environments in Morocco. I therefore suggest that it is the particular combination of these contextual factors that explains the growing prevalence of obesity among women and the persistence of gender difference in prevalence rates.

Data, methods and measures

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. Data, methods and measures
  6. Main findings and discussion
  7. The impact of marital status
  8. The impact of age
  9. The impact of socioeconomic status
  10. Conclusion
  11. Acknowledgements
  12. References

To study the factors associated with obesity and household roles, qualitative fieldwork was undertaken in Rabat and its environs to collect information on how cultural contexts and social and economic factors interact to alleviate or exacerbate obesity differentials between men and women in 20 households. The qualitative study was informed by the findings of a quantitative analysis of the National Cardiovascular Survey (2000), a nationally representative survey of Moroccan adults aged 20 years and above (see Table 1).

Table 1. Proportion obese by marital status, age, economic class, education, employment status, and place of residence (N = 1,789)
 MaleFemale
Marital status
 Single3.02.4
 Married9.524.4
 Widow0.023.8
 Divorced12.529.7
Age
 20–345.411.6
 35–448.430.2
 45–5410.930.2
 55–647.925.2
 65+9.214.0
Economic class
 Low6.720.4
 Middle13.734.7
 Mid-High18.828.6
Education
 None6.119.8
 Koranic6.258.8
 Primary9.730.2
 Secondary11.724.2
Employment status
 Not employed7.321.8
 Employed8.722.7
Place of residence
 Urban10.828.4
 Rural5.714.9
Total7491,040

The qualitative data collection took place in the capital city of Rabat, the second largest city in Morocco after Casablanca. Rabat is a fairly typical Moroccan large city though it is characterised by migrants and government employees. Approximately 90 per cent of industry in the country is located between Rabat and Casablanca, and residents throughout Morocco are drawn to the Rabat area with hopes of employment and a better life. Being a city of migrants, it is also home to an ethnically and linguistically diverse population. And as the centre of government, Rabat is also home to cultural centres, non-government organisations, Western restaurants, and gyms. Consequently, there is also a significant portion of the population in Rabat that is employed by the government, thus creating a sizeable middle-class population, often nonexistent in other major cities in Morocco. Rabat was chosen based on the findings of the survey data, which indicated that urban areas in Morocco have a higher prevalence of obesity (21% versus 11% in rural areas). In addition, urban areas illustrate the new roles held by women in this newly industrialised environment (Popkin 1993).

I selected individuals and subsequently households from S.O.S. Diabete, a grassroots non-profit association that provides education and lifestyle management (diet and physical activity) support for low- and middle-income men and women in Rabat and its environs. I conducted two rounds of semi-structured interviews and observation within 20 households of the women selected from the site described above. In consultation with the professional staff at the association, I used the WHO (1997) criteria of obesity to select the women for this study. In each household there was at least one obese woman. I also calculated BMI as part of the household interviews. Both male and female household members participated in semi-structured interviews used specifically to collect data on attitudes about specific topics, such as traditional sex roles and their distribution, material lifestyle, body image ideals, knowledge of disease etiology, and household composition. As such, observations were centered on the daily household activities of men and women in order to disentangle how their household roles affected their health.

Main findings and discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. Data, methods and measures
  6. Main findings and discussion
  7. The impact of marital status
  8. The impact of age
  9. The impact of socioeconomic status
  10. Conclusion
  11. Acknowledgements
  12. References

The main findings suggest that gender roles explain women's increased likelihood of being obese as compared with men in the Moroccan context. I conceptualise that marital status, age and socioeconomic circumstances are determinants of women's household roles in Morocco.

The impact of marital status

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. Data, methods and measures
  6. Main findings and discussion
  7. The impact of marital status
  8. The impact of age
  9. The impact of socioeconomic status
  10. Conclusion
  11. Acknowledgements
  12. References

The data suggest that women's roles associated with marriage may be what contribute to their risk of obesity. Upon marriage a woman becomes the primary caretaker of her husband and, upon giving birth, she takes on the additional household role of being solely responsible for childrearing. As such, a woman's role as mother is an integral aspect of her role as wife. The combination of these two marital roles most often confines the social roles of married women to within the household:

Before I got married, I was able to leave the house whenever I wanted to. I used to go for nightly walks with my friends. Now I have too many activities in the house to have time to leave (Fatiha, age 35, married, high school educated, 2 daughters, 1 son).

Before marriage, women like Fatiha are more socially mobile and may have the opportunity to participate in activities outside the home. In fact, Mubarek, a married 33-year-old man, commented that if he sees a woman alone late at night on the street he assumes that she is a prostitute.

The additional household tasks associated with marriage generally prevent married middle class women from participating in activities outside the home. The story of Fatiha illustrates how the activities associated with the role of marriage may influence her obesity risk. Prior to marriage, Fatiha worked as a nursery school teacher. She continued to work when she got married, but after the birth of her son she stopped working. She explains: ‘It was no longer possible for me to work and to take care of my tasks at home. I planned to go back to work once he went to school, but by then I had another child’. Her children, Touria (age 8), Naima (age 6), and Khalid (age 11), all attend school. Fatiha is responsible for all the household work. She commented that she wants to continue her education, but as she explains, ‘I don't have time’. One of her concerns was that if she went back to work she would be forced to neglect activities associated with her marital role: ‘No one would prepare couscous on Friday’.

Fatiha's situation demonstrates how a household's social and economic status moderates the relationship between marital status and obesity risk. For example, if Fatiha were of a higher or lower economic class she would be more likely to return to work and possibly decrease her risk of obesity. For example, if she were of a higher economic class she would have a maid, and if she were of a lower economic class she would work outside the home out of economic necessity. Fatiha's particular social and economic status reinforces the marital roles that are associated with an increased obesity risk.

Another explanation for the effect of marital status on obesity risk is that marriage creates a pattern of sex-segregated social space (Mernissi 1975). According to Mernissi, marriage in Morocco is not intended to be characterised by ‘emotional growth in the conjugal unit’, but rather it is the intention of institutions, such as polygamy, to prevent married men and women from investing in each other emotionally (1987: 115). Thus, Moroccan society can be distinguished by institutionalising a weak marital bond through which a gender-segregated space in the household is maintained. This is changing with Moroccan women increasingly delaying marriage (Ayad and Roudi 2006).

The institution of marriage in Morocco is based on a non-egalitarian division of household labour (as described above) and resources. This often takes the form of married women not having access to the same quality and quantity of food as married men, which may deleteriously affect their nutritional status.

The household of Rachida illustrates how this might operate. In this particular household men and women ate at separate tables. The male household members were served first by Rachida's two daughters, Naima (age 21) and Fatima (age 23). The men in this household were brought their tajine (Moroccan slow-cooked stew) first. Then Naima and Fatima brought the woman's tajine to their separate table where Rachida had been sitting. What appeared to be the same meal was in reality quite different. The men's tajine consisted of meat, potatoes and carrots in a vegetable-oil-based broth, whereas the women's tajine only contained potatoes and carrots in the same broth. The women and men consumed roughly equal amounts of bread with the tajine. However, the caloric and nutritional values of the two meals were quite different. This difference reflects what Gittelsohn (1991) points out in his study of Nepal, a difference in nutritional quality rather than quantity. Even if men and women shared a tajine, the men would eat the protein and leave the women with most of the tajine oil base. Men and women, however, would have equal access to bread. In only two of the 20 households that I observed, did men have access to a greater quantity of food, but the same quality as women. For example, in these households men and women ate the same food in terms of quality, but male household members were the only ones with the option of second servings. If the male household members refused the second serving (i.e. another prepared tajine), the women generally would then eat a second portion.

In sum, how food is distributed was observed to reflect the economic positions of the households rather than solely cultural beliefs and practices. In addition, regardless of how food was distributed at meals, women in all the households snacked in between meals, especially during cooking. As such, meals are not the only source of women's calorie consumption.

The impact of age

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. Data, methods and measures
  6. Main findings and discussion
  7. The impact of marital status
  8. The impact of age
  9. The impact of socioeconomic status
  10. Conclusion
  11. Acknowledgements
  12. References

The narratives also suggest that age is a primary factor associated with a woman's household roles and her eating and physical activity patterns in Morocco. A woman's household roles change with age and become increasingly more sedentary. In addition, women generally gain social status with increasing age, which is associated with greater sedentary activity (Lloyd and Gage-Brandon 1993).

The story of Fatima Zohra (age 47, primary-level education, 3 daughters, 4 sons) illustrates how age determines one's household roles. In this particular middle class household, the youngest daughter (Touria, age 7) attends school and the oldest daughter (Khadija, age 21) is engaged. Hasna, according to her mother, ‘does everything in the household. I am now being rewarded for my years of work. I am tired’. She assists in the preparation of tea and other special items as part of the ritual of hospitality, but otherwise she spends most of her time delegating tasks to Hasna and/or watching television. The oldest, soon to be married, daughter (Khadija) also helps minimally with household tasks, but is otherwise sedentary. Her main responsibility is the household shopping. On a daily basis this may include her going to the corner hanut (local store) and buying the daily ration of bread and/or eggs. Otherwise she spends the day with her mother watching television. She used to perform the energy-exerting household tasks with her younger sister prior to her engagement. Hasna now performs the majority of the household tasks. These tasks primarily include all the cooking and cleaning for the entire household. Indeed, the preparation of food and domestic chores in the majority of Moroccan households is particularly labour intensive because of the lack of modern conveniences. Vacuum cleaners, food processors, dishwashing machines, washing machines or microwaves are relatively rare, except in particularly wealthy urban families.

The household tasks of men are less dependent on their age. The four sons in the household do not assist in any of the domestic tasks. The youngest two (Mohamed and Khalid) attend school and the oldest (Rachid) works at a café as a waiter. In Morocco, men work in restaurants as cooks and servers. These same men would not perform these types of tasks within their own home, but do so for pay outside the home. The second oldest son (Ismael) is unemployed. He wakes up at approximately 2pm each day and eats the lunch that his sister has prepared for him. Then he returns to sleep for an hour in the late afternoon. After that, he leaves the house and spends most of his time at cafés until he returns home for dinner at approximately 10pm. He plays soccer a few times a week and sometimes goes to a nearby gym where his friend works in order to lift weights. The husband (Said, age 64) also does not assist with household chores in any capacity. He is a retired teacher and spends most of his time outside the house playing backgammon at the nearby café while he drinks coffee and smokes.

With increased age, both male and female household members gain social status in Morocco. For example, a mother-in-law has a powerful role in Moroccan households. One way this manifests itself in terms of obesity risk behaviour is through eating order. In Fatima Zohra's household, the male members were served before the women and they were served according to age (oldest to youngest). Fatima Zohra, however, was given the largest piece of meat relative to the other female household members. Thus, with increasing age a woman's food consumption increases or stays the same, but her physical activity decreases. This change in activity level often coincides with the menopause, a time which is associated with increased female abdominal adiposity (Sternfeld et al. 2004).

In general, my household observations suggest that higher social status is associated with a more sedentary lifestyle within the household. For instance, mothers and mothers-in-law were observed to be relatively sedentary and with increasing age their social roles become increasingly more confined to within the household walls. Yet generally fathers, despite their older age, hold social roles outside the household and remain physically active.

The impact of socioeconomic status

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. Data, methods and measures
  6. Main findings and discussion
  7. The impact of marital status
  8. The impact of age
  9. The impact of socioeconomic status
  10. Conclusion
  11. Acknowledgements
  12. References

Socioeconomic status was observed to moderate the relationship between the risk of obesity and gendered household roles as demonstrated by the story of Mubarka, a 54-year-old non-obese woman who worked as a maid in a wealthy household in Rabat. She had never attended school and was illiterate. She was a widow with two married daughters. Most women of her age, as described above, have relatively sedentary daily activities and are more likely to be obese. However, I observed Mubarka's daily activities to be much more analogous to the energy-exerting household tasks of a younger female household member, such as Hasna (described earlier). She is responsible for the cooking and cleaning of her employer's household and her own household. Mubarka claims that she has no plans to stop work because, as she says, ‘I have no choice’.

In contrast to the United States, where a more sedentary lifestyle for women is correlated with low socioeconomic status (Yancey et al. 2004), in Morocco a more sedentary lifestyle for women is associated with middle and/or high economic class. Women of the middle and/or high economic class do not have to work out of economic necessity. Thus, their lifestyles are more congruent with the cultural norm which rewards women of increasing age with more sedentary household roles. The particular household roles associated with this more sedentary lifestyle, however, were observed to be associated with an increased obesity risk. In contrast, women of the highest economic classes were observed to be significantly less likely to be obese because they or other household members had higher levels of education and/or they held body image ideals that valued thinness.

Morocco is characterised by women having overall low rates of education, particularly at high levels (i.e. university) (UNDP 2005). In addition, obesity has yet to be fully medicalised in Morocco. Medicalisation refers to ‘the process by which certain behaviours or conditions are defined as medical problems’ (Chang and Christakis 2002). I found a generally inaccurate knowledge of obesity etiology among the participating households. For example, of all the household participants, about a quarter of individuals stated that obesity was usually caused by overeating and a few said that they did not know the cause of obesity. However, the majority of those interviewed agreed with the statement that obesity was caused by not getting enough exercise. Several of the men, however, added that this was particularly true for women who did not exercise. A small minority of respondents said that obesity was not related to exercise, but rather ‘you are born with it’. A consistent number of individuals stated that they did not know the relationship between exercise and obesity.

The most common explanation for female overweight/obesity provided by participants is that women give birth to children. This is consistent with the observation that most women view motherhood as their most central household role. Yet, none of the women interviewed could provide one explanation for male obesity. Several of them said that men ate too much meat, men smoked, and men were lazy (magaz). Another explanation for obesity, given by several men, was that Moroccans no longer had to use their hands to farm, so they had become overweight.

Based on in-depth household interviews, women with university levels of education were observed to be more likely to have accurate knowledge of obesity etiology. They were also more likely to be employed and thus be exposed to health knowledge. In addition, women with a university level of education are more likely to be of higher economic classes and thus their associated material lifestyle may reduce their obesity risk. In contrast, women with lower levels of education might be more likely to hold inaccurate health knowledge. In sum, the effect of education on women's obesity risk may come from knowledge of obesity etiology, rather than solely through pathways generally associated with socioeconomic status (i.e. credentials that impact one's adult lifestyle, such as employment and income).

Another pathway through which economic class may mediate obesity risk is through a woman's particular body image ideals. A slim body image ideal was observed to be pervasive among the higher economic classes in Morocco. As such, these women have lifestyles that promote the attainment and maintenance of such an ideal (i.e. being on diets (regime), joining a gym, etc.). Studies that have been conducted show an increasing influence of Western culture infused through technology into Muslim societies through media such as satellite television, and magazines (Luepker 1999, Wang et al. 2002). These external forces have been shown to engender a desire on the part of women, particularly adolescent girls, to be thin (Wang et al. 2002, Field et al. 1999, Kaneko et al. 1999). In addition, it has been suggested that the availability of tighter high fashion clothing in the Middle East and North Africa that emphasises the body's shape has led to an increasing awareness of body size (Basyouny 1998).

However, access to these types of material items is most often determined by economic class, as well as generation. I observed an important generational effect of the relationship between body image ideals and obesity risk-related behaviours. Overall, the obese women in this sample belonged to a generation which was exposed to larger body image ideals on television (before Western ideals of beauty became prevalent in Morocco). These images on television resembled the only socially valued role available to them at that time (i.e. mother). Having a larger body was thus associated with being a mother. Therefore, this ideal body image may have influenced their subsequent obesity risk-related behaviours.

In sum, the general consensus among the men and women interviewed was that the traditional veneration of a large body size for women is no longer a significant social value in Morocco. Obesity is no longer considered a sign of affluence or fertility for women. This was reflected by responses to the question: who do you think is the wealthiest? All the women selected a silhouette in the ‘thin’ category, suggesting that a smaller body size was in fact a sign of higher economic class.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. Data, methods and measures
  6. Main findings and discussion
  7. The impact of marital status
  8. The impact of age
  9. The impact of socioeconomic status
  10. Conclusion
  11. Acknowledgements
  12. References

Despite the gendered characteristics of obesity in Morocco, no research has systematically examined why Moroccan women are more likely to be obese than Moroccan men. Certainly, nutrition transition theory that explains weight gain as caused by the changing diets available to people as their societies modernise is inadequate. Similarly, the notion that a large body is universally venerated in Arab society (Naik 2004) also does not explain the rising rates of female obesity. However, I demonstrate in this research that the relationships between cultural forces (such as certain ideas about beauty and space) and structures (such as social class) are far more complex and multidimensional than presented by these overly simplistic accounts of obesity in this region.

This research focuses on how gender operates to affect obesity risk in the Moroccan context and helps to answer the question of the gender discrepancy in the rates of obesity. Although no one theory can explain the gendered nature of obesity in Morocco, I suggest that we can explain the significant difference in male and female obesity rates through an examination of men's and women's household roles conceptualised to be determined by marital status, age and socioeconomic status.

This article calls upon researchers to further consider how household organisation might influence the health status of particular household members through a combination of both qualitative and quantitative methods. Other studies have demonstrated that unequal resource distribution was related to undernutrition (Gittelsohn 1991, Pitt 1983, Graham 1997), but obesity has yet to be considered in this light. There might be a particularly salient relationship between unequal resource distribution, including education, for households that distribute resources unequally based on gender. This type of research would provide a better measurement of gender/family systems that would allow us to test empirically the importance of cultural contexts in understanding gendered health outcomes.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. Data, methods and measures
  6. Main findings and discussion
  7. The impact of marital status
  8. The impact of age
  9. The impact of socioeconomic status
  10. Conclusion
  11. Acknowledgements
  12. References

This research was funded by grants from the American Institute of Maghreb Studies, the Mellon Foundation, the Population Studies Training Center, Brown University, and the Joseph H. Fichter Sociology of Religion Award. I gratefully acknowledge their generous support. I also thank the respondents for spending their valuable time speaking with me and sharing their experiences.

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  2. Abstract
  3. Introduction
  4. Background
  5. Data, methods and measures
  6. Main findings and discussion
  7. The impact of marital status
  8. The impact of age
  9. The impact of socioeconomic status
  10. Conclusion
  11. Acknowledgements
  12. References
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