The arrival of fast food has triggered the latest health epidemic to hit developing countries. As doctors begin the fightback against morbid obesity, Bénédicte Desrus travels round Africa photographing people living with the condition, while Ian Birrell reveals why South Africa now faces its biggest challenge since HIV

When the first McDonald’s restaurant opened almost two decades ago in Johannesburg, a teenage boy named Thando Tshabalala was among the thousands who stood in line patiently waiting to try one of those famous burgers. “We had seen this place in every movie we ever watched, and it seemed to be mentioned in every song, so I had to try it for myself,” he said.

Given such enthusiasm, it was hardly surprising that South Africa proved to be fertile territory for the burger chain, breaking expansion records with 30 outlets opening in under two years. Today the company operates more than 200 restaurants across the country. When arch-rival Burger King finally entered the market last year it was greeted with similar excitable scenes – almost 5,000 people descended on its launch branch in Cape Town, some even sleeping on the street to ensure they got their hands on a Whopper. “We did not expect the demand to be so great,” its chairman confessed later.

Tshabalala, now a successful 33-year-old corporate trainer, still enjoys fast food. When we met he was eating a steak sandwich in the food court of a smart shopping mall, sitting among scores of shoppers and families feasting on curries, pizzas, fried fish and the ubiquitous chips. But that skinny teenager has grown into a 5’5” man weighing almost 17 stone – and today he struggles to find clothes to fit his inflated body and complains that seats are becoming too small for comfort.

“To be honest I feel rather self-conscious about my size,” Tshabalala told me with a rueful smile. “There is this saying in South Africa that if you have a one-pack belly, like a beer belly, you must have lots of money, but if you have a six-pack there is something wrong. But I know it is not really a sign of success to have a big belly.”

Sitting with him was his girlfriend Fiona Sefara, an entrepreneur building a recycling business. A former vegetarian, she recalled leaving South Africa before the end of apartheid to live in America. “When I went there I was surprised to see all these overweight people on the streets – but when I came back home, McDonald’s was everywhere and there were all these bigger people on our own streets.”

As we chatted, she chided her partner for his fondness for fried food and huge portions, then confided that the worst aspect of the change in her homeland was seeing so many overweight children. “We had nothing as children so we’d take a tennis ball outside and play for hours until it was dark. But now they have computers and are driven everywhere,” she said. “My own nephew is so chubby that he has become one of those American kids.”

Facebook Twitter Pinterest ‘My belly gives me so much’: Ugandan dancer Moses Kawooya, 59, weighs 243lb and performs for visiting presidents with his ‘magic belly’. His dad and grandfather had the same physique, and it earns him a living. Photograph: Benedicte Desrus

Fat is no longer just a developed world problem. Forget those tired old clichés beloved by the aid industry. Today more people in poorer countries go to bed each night having consumed too many calories than go to bed hungry – a revelation that underlines the breakneck pace of change on our planet. A landmark report by the Overseas Development Institute earlier this year showed that more than one-third of the world’s adults are overweight – and that almost two-thirds of the world’s overweight people are found in low and middle-income nations. The number of obese or overweight people in developing countries rose from 250 million to almost 1 billion in under three decades, and these rates are rising significantly faster than in rich nations.

South Africa typifies this alarming new trend, with nearly double the average global obesity rates, and according to another report has become the world’s third fattest nation. Nearly two-thirds of the population is overweight and, unlike in the developed world, the problem afflicts more women than men. Incredibly, 69.3% of South African females display unhealthy levels of body fat and more than four in 10 are clinically obese (defined as having a BMI higher than 30).

These findings emerged in a Lancet study published in May which analysed data over a 33-year span from 188 countries. It found the rise in global obesity rates was “rapid, substantial and widespread, presenting a major public health epidemic in both the developed and developing world”. More than half the women in Botswana and one in eight Nigerian men are also obese, for example, while Egypt saw one of the fastest rises among women.

Obesity is on the rise in poorer nations even among children; more than a quarter of girls and almost one in five boys in South Africa is overweight. “These are devastating figures, especially since it is such an expensive disease,” said Professor Tess Van der Merwe, who performs weight-loss surgery and is president of the South African Society for Obesity and Metabolism. “We cannot afford to spend the next decade debating this issue. The obesity problem in our country is where the HIV epidemic was 10 years ago, when we turned a blind eye to the scale of the problem in terms of health economics and became the worst in the world in terms of outcomes.”

Terrifying talk for a nation in transition that provides only rudimentary healthcare for most of its population and where a quarter of citizens still struggle with food security. Experts say such diseases such as cancer, cardiovascular conditions and diabetes will soon overtake HIV and tuberculosis as the biggest causes of death in South Africa.

One man who understands the scale of South Africa’s challenge is Aaron Motsoaledi, a 56-year-old doctor from Limpopo and the country’s current minister of health. “It is weird when we are seeing malnutrition co-exist alongside obesity,” he told me. “I am not only sad but also alarmed, because of my medical training. In the next decade many countries will not be able to afford their health costs, and this definitely includes South Africa.”

Facebook Twitter Pinterest ‘I was born big. I was always like this’: Susan Kalai, aka Mama Safi, is 53, has seven children and lives in Kawangware slum in Nairobi. She can barely walk and suffers from numerous weight-related diseases. Photograph: Bénédicte Desrus

Motsaoledi believes the problems fit a global pattern of obesity caused by the rapid shift to urban living combined with increased consumption of western-style diets high in sugar, fat and salt. The problem has worsened in South Africa since it is a nation whose love of meat barbecued on the braai cuts across ethnic boundaries – the two groups hit hardest by obesity are white Afrikaner males and black urban females. On top of this, fears over crime have boosted car culture, with cities designed around US-style shopping malls and fewer children running free in the streets.

“Thirty years ago black people in South Africa were eating produce from fields that was much healthier, and they were walking big distances,” said Motsaoledi. “When I was a child pupils would walk 6km to school; some even walked 10km each way. Now life has changed and people do not want to walk anywhere.”

The health minister tries to set an example, dropping a few clothes sizes after cutting down on meat and eating more fish and vegetables. But not all the country’s political leaders are so diligent – last year there was a scandal after it was discovered that the premier of one province used her government credit card to spend nearly £3,000 on fast food in her first 10 weeks in office at outlets such as KFC and Wimpy. And Motsaoledi complains he is dismissed as a health fanatic while food companies chasing profits ignore his attempts at regulation.

Efforts to grapple with this obesity epidemic show the special problems this global concern causes among poorer people in developing nations. One sunny Monday morning I drove to Soweto to visit Petrus Molefe Park, named after a local hero of the liberation struggle. Two years ago the city council installed an impressive “green gym” for residents. Sure enough, the first person I met was the perfect promoter for the idea: an unemployed man named Vusi, who told me he spent two hours every day pumping iron after abandoning his unhealthy lifestyle.

Then we were joined by three young women, who confessed this was the first time they had come along in a bid to lose weight. I started talking to Octavia Mphumbude, who was tentatively testing a running machine in her turquoise jeans and black cardigan. “I won’t lie – I like junk food a lot,” said the 25-year-old single mother, who has never managed to find a job despite intensive efforts and voluntary work. “The trouble is, when I am hungry I crave fast food. It is hard to resist. And many of the women around here are unemployed, like me, so if you’re unhappy it’s comfort food. This is why weight is an issue for us.”

Unfortunately poor people fill their bellies with cheap food – and this often means salt-drenched starchy carbohydrates, highly processed sweetened products and the fattiest cuts of meat discarded by wealthier consumers. Street-food surveys found that chicken sold in townships is often little more than skin and other meat is just fatty offal, while foreign fast food is seen as sophisticated. Meanwhile mothers go without meals to ensure that their children eat, then gorge when they have money.

All this can lead to “hidden hunger”, when people eat regularly and even put on weight but lack necessary nutrients and vitamins, leading to long-term health damage. “In one household you can see children who are undernourished, the man with normal weight and then the wife who may be heavily overweight,” said Zandile Mchiza, an expert with the Chronic Diseases of Lifestyle Unit at the Medical Research Council. “This is why we have the issue of obesity coming up so strongly in Africa even while many people are still starving.”

Mchiza also pointed to cultural issues that fuel obesity in Africa, with big men seen as successful and big women seen as beautiful. “The majority of black South African men prefer chubby women,” said the 34-year-old scientist. “If you are too thin it means your husband is not taking care of you or you are unhappy. And your children must be fat, too – we were force fed growing up, always told to eat up all our food and not waste anything on our plates.’

I heard similar claims from other experts – and certainly a glance at the internet indicates specialist dating sites for “cuddly” people are booming. A study last year by the Human Sciences Research Council found that 88% of South Africans regard a fat body as their ideal.

Facebook Twitter Pinterest Weighing in: Ruth Gathu, 35, after a workout with her nutritionist. She weighs 299lb and says: ‘Obesity is in all social classes’. Photograph: Bénédicte Desrus

Several township women mentioned told me of another depressing reason not to diet. “There is a stigma that if you are a black woman and start losing weight you might be ill, you might have HIV,” said Dudu Masooana, a friendly 38-year-old mother of three from Soweto whom I met as she lunched on fried chicken and pap, a traditional porridge made from ground maize. “This really matters if you are a woman coming from the ghetto.”

A host of parasitical industries have grown up to feed off the obesity crisis, from quack diets and hypnotism at one end of the spectrum to fitness boot camps and bariatric surgery at the other. Television has also got in on the act, with reality shows encouraging people to turn their lives around by exercising and improving diet. One of the most popular is Kabelo’s Boot Camp, hosted by a pop star who became a poster boy for healthy living after defeating a drug problem and losing 100lb. Now Kabelo Mabalane runs marathons, eschews substance abuse and puts 10 South Africans selected from the thousands of hefty applicants through their paces on his 11-week show.

“We used to associate wealth with a big tummy and had the idea that if you were skinny you were not doing well,” he told me. “It is only now, 20 years after democracy, that we are dealing with these issues and educating people about the dangers of overeating and obesity. It’s a physical transformation, but you have to deal with the issues inside the head, too.”

There are signs that the government recognises the need for action, with the vice president set to lead a commission to bring together academics and officials from different departments to find urgent solutions. The hope is to get the nation to take notice of the crisis; the outlawing of trans fats was ignored by the food industry and the government lacked the ability to police the measure. There has been action taken to reduce salt in processed foods such as bread and talk of a ban on alcohol advertising, provoking outrage from a powerful industry.

But this is a global crisis. And the surge in South African obesity is simply one more sign that, from Cape Town to Cairo, a continent for too long seen as the poor relation is catching up with the rest of the world as it rapidly grows and urbanises. Obesity is growing faster globally than any other cause of disease. Mexico has rates to match the United States, while the number of overweight people in China – a country that endured horrific famine within living memory – has near-doubled since 1980 as teenagers guzzle fast food and parents shower sweet treats on their solitary children.

There are attempts to grapple with this crisis: restricting trans-fatty acids in Denmark, imposing taxes on fizzy drinks in Mexico, even fines for employers of overweight staff in Japan. But there was one more chilling fact in that recent Lancet study looking at three decades of obesity around the world. Not only is one-third of the planet’s population too fat – with those numbers rising daily and the problem hitting women especially hard – but perhaps most frighteningly of all, not one of the 188 nations studied managed to reduce obesity levels over the period studied. Truly, as the fast-food joints and shopping malls of South Africa show, this has become a global health and social crisis of gargantuan proportions.

This is an edited version of an article that appeared in Mosaic: the Science of Life, a digital publication from the Wellcome Trust (mosaicscience.com)