The global agenda on obesity: what does this mean for Singapore?

INTRODUCTION

Obesity is undoubtedly a global health crisis, impacting approximately 15% of adults globally in 2020.[1] Perpetuated by the global obesogenic environment and the coronavirus disease 2019 (COVID-19) pandemic, which has significantly impacted health-related behaviours,^[2–7] obesity prevalence is expected to accelerate in the absence of potent stop measures. By 2030, obesity is predicted to affect more than 1 billion adults, or one-sixth of the world's population.[1] The World Obesity Federation (WOF) estimates that between 2025 and 2030, the number of children and adolescents with obesity will rise by about 50 million.[8]

As a multifactorial disease, obesity stems from a dynamic interplay of an individual's genetic predisposition and a plethora of biological, psychosocial, socioeconomic and environmental factors.[9] An individual's susceptibility to obesity can start as early as the prenatal period.[10,11] Therefore, to effectively address obesity, strategies are needed that synchronously tackle multiple facets in the entire health ecosystem and drivers of obesity throughout the life course.

THE GLOBAL AGENDA ON OBESITY

Obesity accounted for 12% of all deaths due to noncommunicable diseases (NCDs) in 2019.[12] As part of the World Health Organization (WHO) Global Action Plan for the prevention and control of NCDs 2013–2020, attaining the target of zero growth in obesity by 2025 (against a 2010 baseline) is critical in reducing premature mortality from NCDs by one quarter by 2030.[13]

In 2022, the 75^th World Health Assembly (WHA) adopted a comprehensive set of recommendations for the prevention and management of obesity over the life course, building upon its commitment to address NCDs.[12,14,15] This sets the stage for the Global Action Plan on obesity, a much-needed response for a coordinated and comprehensive roadmap for countries to implement the recommendations.[12,14,16] Complementing these recommendations is the Acceleration Plan, which provides an overarching framework for WHO to support accelerated implementation of these recommendations in selected frontrunner countries to tackle obesity, ensuring necessary resources are available and requiring accountability. The Acceleration Plan sets aggressive yet achievable targets to address obesity[12] [Box 1]. The success of the recommendations will require strong commitment of country leadership and the adoption of whole-of-society approaches.

Box 1.

Key highlights from the 75^th WHA of the WHO on recommendations for prevention and management of obesity over the life course and the WHO Acceleration Plan.[12,14,16]

The WOF key highlights from the 75th WHA document on recommendations for the prevention and management of obesity[16]

• Recognises obesity as a complex multifactorial disease

• Acknowledges the stigma and bias experienced by people living with obesity in different geographies and cultures

• Recognises the need to prevent and manage obesity throughout the life course

• Recommends improvement in the training of healthcare providers in obesity management

• Recommends inclusion of obesity in universal health coverage packages, and management through multidisciplinary teams

• Recognises the need to build on existing strategies

• Highlights the importance of regulating food environments through taxation and incentives

The WHO Acceleration Plan[12,13,14]

• WHA target: Aims to halt the rise of obesity in children and adults by 2025 (against a 2010 baseline)

• Relies on country leadership, political commitment and the adoption of a whole-of-society approach, where everyone, including people living with obesity and their families and communities, plays a part in tackling obesity The five workstreams through which the Acceleration Plan will be implemented are as follows:

1. Identify priority actions for greater impact on the prevention and management of obesity throughout the life course 2. Support implementation of country actions

3. Communicate rationale for action, advocate for the adoption of WHO recommendations and targets, and acknowledge progress

4. Promote the engagement of multiple stakeholders in support of country action

5. Monitor progress towards global obesity targets

WHA: World Health Assembly, WHO: World Health Organization, WOF: World Obesity Federation

THE STATE OF AFFAIRS IN SINGAPORE

Within a short span of a few decades, Singapore has undergone rapid economic and urban development with a commensurate rise in NCD prevalence and mortality. From 2004 to 2010, obesity prevalence rose by nearly 60%, from 6.9% to 10.8%, with a corresponding 38% rise in prevalence of diabetes mellitus to an all-time high of 11.3% in 2010.[17] In the ensuing years to 2017, the obesity prevalence remained at 8.6%, but rose again to 10.5% in 2020.[18] Obesity results in a plethora of complications, which occur at a lower body mass index (BMI) in Asians. Using the BMI cut-off reflecting the health risk of excess adiposity in Asians, it was found that in 2020, 58% of adults in Singapore were living with an unhealthy weight (BMI ≥23 kg/m²), with 20.7% having obesity (BMI ≥27.5 kg/m²) and 40.6% having abdominal obesity.[19] While the prevalence of obesity among adults in Singapore remained steady from 2010 to 2020, among school-going youths aged 6–18 years, obesity has risen from 11% in 2013 to 13% in 2017 and further to 16% in 2021.[20,21] The COVID-19 pandemic has undoubtedly affected health-related behaviours and weight. The increase of obesity in youths from 2017 to 2021 was mainly observed in 2020–2021 due to the effect of the COVID-19 pandemic.[20] Given that 70% of children with overweight remain overweight as adults,[21] the adult prevalence of obesity will likely increase in the coming decades if effective measures are not implemented in childhood and adolescence.

Correspondingly, Singapore has one of the most rapidly ageing populations globally. Ageing is associated with an increase in abdominal obesity and is a major risk factor for multiple NCDs.[19] Together, ageing and obesity are twin engines that will drive multiple diseases and increase the risk of morbidity and mortality. The forecasted doubling of prevalence of diabetes mellitus to 15% between 1990 and 2050 is attributed largely to an anticipated ageing population and unchecked rise in obesity prevalence.[22] The burden of obesity on our nation is profound.

WHAT DOES THE GLOBAL AGENDA ON OBESITY MEAN FOR SINGAPORE?

National initiatives to promote healthy lifestyles in Singapore have come a long way since the launch of the National Healthy Lifestyle Programme in 1992. With the establishment of the Health Promotion Board (HPB) in 2001,[23] Singapore has continued to make laudable progress in the establishment of infrastructure, implementation of national programmes and regulation of the food environment in a long-term effort to tackle NCDs.[24] Obesity prevention measures are woven into the country's infrastructure, interventions and programmes, with an aim to build an ecosystem of healthy living throughout and around the residents’ lives [Figure 1a]. Some of these measures include implementing food-related policies to restrict the marketing of unhealthy food to children, increasing the availability of healthier food options through programmes (e.g. Healthier Choice Symbol, Healthier Dining Programme, Healthier Ingredient Scheme), and increasing physical activity through ActiveSG programmes, sports facilities and the National Steps Challenge. Over time, there has been an increase in physical activity,[19,25] associated with a reduction in caloric and refined sugar intake and an increase in fibre intake.[26] Yet, we have fallen short of the national targets set in 2010, which were to maintain obesity prevalence at <10% among adults by 2020[27,28] and to reduce overweight among children from the projected 14% to 11% by 2020.[28] If we are to avert the serious downstream effects of obesity, a national roadmap with a whole-of-society strategy concurrently addressing the current gaps and the underlying drivers of obesity throughout the life course is warranted.

Figure 1.

Diagrams show (a) a summary of infrastructure, interventions and programmes in the ecosystem for healthy living; and (b) a life course approach that highlights the importance of the family unit. ^aInitiative under HPB (more information at: https://www.hpb.gov.sg/). ^bInitiative under ActiveSG (more information at: https://www.myactivesg.com/). ^cActiveSG is the national movement for sport initiated by Sport Singapore. ^dLumiHealth is a personalised health programme to encourage adoption of healthy habits using the Apple Watch, developed by Singapore's HPB and Apple Inc. ^eHealthier SG is a major healthcare transformation in Singapore to be rolled out in 2023. Healthier SG consists of five key components: (i) mobilise the network of family doctors to deliver preventive care; (ii) develop healthcare plans for preventive care; (iii) activate community partners; (iv) national Healthier SG enrolment programme; and (v) set up enablers such as digital infrastructure, manpower and financial policy. ^fWHO recommends the following as part of antenatal care: provision of dietary and weight counselling, physical activity counselling, tobacco cessation, measurements of gestational weight gain and exclusive breastfeeding.[14] GP: general practitioners, HPB: Health Promotion Board, MOE: Ministry of Education, NCD: noncommunicable diseases, NHGP: National Healthcare Group Polyclinics, SSB: sugar-sweetened beverages, WHO: World Health Organization

A life course approach to prevent and manage obesity is crucial. With this approach, there is increased recognition of the impact on the family unit [Figure 1b]. The government has recently initiated a taskforce on Child and Maternal Health and Well-being to deliver evidence-based policies and programmes to promote health to children and their families.[29] The Growing Up in Singapore Towards Healthy Outcomes (GUSTO) studies provide compelling data on the impact of prenatal, intrauterine factors and the first 1,000 days of life on a child's health.[30,31,32] Meanwhile, the Singapore Preconception Study of Long-Term Maternal and Child Outcomes (S-PRESTO) is a preconception, longitudinal cohort study that will give insights into the effects of maternal health before and during pregnancy on the offspring.[33] Children with overweight and obesity are more likely to develop cardiometabolic diseases and have poorer psychosocial outcomes than their healthy weight counterparts. They are also more likely to become adults with obesity, further augmenting their risk of obesity-related complications and premature mortality.[9,10] Our children are our future. Moving upstream in the life course for obesity prevention, investing more resources in interventions for people in the reproductive age group, antenatal interventions[34] and parent-focused early childhood intervention programmes[35] should be considered. As for adults, fostering work environments that promote health-related behaviours and obesity prevention should become a priority, as most people spend a significant portion of their lives in the workforce.

In the 75^th WHA recommendations, the WHA recognises obesity as a disease and acknowledges the impact obesity has on global health.[14,16] While there are some alternate views against recognition of obesity as a disease, such as reducing personal responsibility and thereby reducing adherence to lifestyle modification, the WOF and other major scientific organisations take the position that obesity is a chronic, relapsing progressive disease based on medical and biological evidence.[36,37] The disease model approach to obesity acknowledges that, as a chronic medical condition, obesity has its own set of pathophysiology, drivers and associated aetiological factors that need to be addressed as targets of treatment for the long term. Understanding the pathophysiology of energy homeostasis in obesity helps shift obesity treatment targets to underlying biological, psychological, social and environmental factors causing obesity. Acknowledging obesity as a disease reduces blame on people living with obesity (PLwO) and highlights the need for strategies for prevention and management, including provision of education, clinical services and policies.

For people with more severe obesity, larger degrees of weight loss are required for clinical significance. Access to supported lifestyle therapy for people with obesity is the mainstay of treatment. In addition, some would require more intensive interventions such as dietary prescriptions, cognitive behaviour therapy, antiobesity pharmacotherapy and bariatric surgery.[38,39] Referral to tertiary care may be warranted to manage more severe obesity complications. Viewed merely as a lifestyle factor which increases the risk of other diseases rather than a disease itself, obesity treatment in Singapore is mostly an out-of-pocket cost. There is little or no reimbursement by private health insurance, and outpatient costs for obesity are not claimable using MediSave under the Chronic Disease Management Programme (CDMP). With cost as a barrier, there is poor uptake or sustainability of treatments. This challenge is, however, not unique to Singapore.[40] Hence, the WHA recommends the inclusion of obesity in universal health coverage. A reasonable approach would be a stratified obesity care algorithm to better manage the healthcare resources in Singapore. This can entail facilitating referral to tertiary care, reimbursements, subsidies and use of MediSave under the CDMP for obesity treatment for people with more severe obesity. Local studies on the cost-effectiveness of obesity treatment can further inform strategies that best benefit PLwO with judicious use of healthcare resources.

The 75^th WHA recommendations also acknowledge the stigma and bias experienced by PLwO. This acknowledgement is a systemic change in mindset to regard obesity as a chronic disease and as an urgent public health priority. Weight stigma is a psychosocial contributor to obesogenic behaviours. It may impede update of obesity treatment and negatively impact health outcomes.[41] Often, obesity is regarded simply as the consequence of ’more in, less out’ and thus the moral failing for the lack of discipline over one's lifestyle. PLwO often hold themselves as solely responsible for managing their obesity. This cascades down to development of weight bias and stigma and further perpetuates the ill effects of obesity.[42] Some PLwO may attempt non-evidence-based or potentially dangerous obesity treatments while accruing greater health problems before professional help is sought. As healthcare providers, we can adopt strategies to reduce weight stigma.[43] Recently, a joint international consensus on ending the stigma of obesity was developed to inform healthcare professionals, policymakers and the public about this issue, to facilitate change in the narrative about obesity that is coherent with current scientific knowledge.[37] Weight stigma is poorly studied and barely addressed in Singapore. Addressing weight stigma and studying potential interventions to reduce it is an imperative step if we were to holistically manage obesity.

Another barrier is unfamiliarity with obesity management among healthcare providers, as healthcare education in obesity is not prioritised locally. The WHA recommendations recognise the need to ensure healthcare workers are trained in obesity management and recommend obesity to be included in medical training. With the initiation of a preventative health model of care by the Ministry of Health, Singapore, with Healthier SG in 2023, obesity will be a key focus of care.[44] The role of primary care providers (PCPs) in managing obesity and its complications has never been more pivotal. Resourcing, with governmental support and prioritisation, is urgently needed to educate and upskill the PCPs so as to provide multidisciplinary support in the community with trained allied health professionals. While many medical associations, healthcare and academic institutions, and private industry partners are working to provide support, consolidated efforts (both cross-cluster and intersector) can result in greater headway while making wise use of resources. The formation of a national platform to share resources and best practices can facilitate this effort. Furthermore, the establishment of a national institute for obesity and metabolic diseases may serve to consolidate efforts for the study of obesity, ranging from basic science to clinical management and public health interventions. In addition, with the transformation of our healthcare system with upgrading of digital infrastructure and data analytics, a national prospective database can potentially inform areas such as the drivers of obesity across the life course, particularly the psychosocial determinants of health, effective obesity interventions and public health policies unique to Singapore.

As a transformative healthcare strategy for the nation to be implemented in 2023, Healthier SG aims to shift focus of healthcare delivery to health promotion and disease prevention, in the light of an ageing population and the burden of NCDs. Maintaining a healthy weight and/or management of overweight and obesity is a key target as part of control of NCDs. Under the care of one family doctor, residents will have individualised care plans, which include social prescriptions and activities supported by community partners and regional healthcare clusters. Resources, including structured programmes to maintain healthy weight and to manage obesity, will be available at the community, primary and tertiary levels through care protocols. Harnessing digital technology, HPB will enhance the mobile application, Healthy 365, to enable residents to better track and improve their physical activity levels and dietary/lifestyle habits, as well as to support their access to community activities with the aim to nudge residents to adopt healthier lifestyles.[44]

Indeed, with the progress of national and community infrastructure for healthy living, Singapore has made great strides in addressing obesity and in its effort towards control of NCDs. While Singapore has not pledged to be a frontrunner country for the Acceleration Plan at the 75^th WHA, we should continue to advocate for more public resources and commit to the implementation of the key recommendations in obesity prevention and management. We need bold coordinated national action with various ministries, community groups and businesses, together with primary care, tertiary care, academic institutions, healthcare professional groups and PLwO. In addition, we need to strengthen other measures, such as ongoing public education, regulation of the food environment (particularly in schools and retail outlets), availability of affordable healthy food options, partnership of private and public sectors in digital health technology, and provision of support services. These multipronged measures could be thoughtfully incorporated under a national plan with short-, mid- and long-term goals.

Singapore has taken a bold step in rolling out Healthier SG and incorporating obesity rates as a key outcome. The crucial issue is now a matter of implementation of these new healthcare models and other supportive measures. Effective implementation and rigorous support for this healthcare transformation, together with recommendations from the global action plan, could well accelerate Singapore to fulfil the urgent need to address obesity and become a healthier nation.