With one in five Singapore residents living with obesity, it is timely that we debunk deep-seated myths about this chronic disease and consider ways to prevent and treat it safely.
When you tell people you have a chronic disease like high blood pressure, you may get sympathetic responses like "Oh, you must be stressed" or "Try to take things easy". Yet when you are overweight or have obesity, people may make remarks like, "Wow, you've put on weight" or disparaging jokes like, "Don't trip or you might break the floor".
Often, those who are overweight or have obesity are viewed as greedy, lazy, and lacking in self-control and willpower. Faced with such stigma, it is easy to understand why those living with obesity often suffer from poor self-esteem, depression, and helplessness. This may pose a barrier to seeking professional help.
"Firstly, it's important to recognise that obesity is a chronic disease, and that it is no different from other better-known chronic diseases such as diabetes and high blood pressure," emphasises Dr Marvin Chua, Consultant, Department of Endocrinology at Sengkang General Hospital.
"Obesity is not an issue of willpower or poor lifestyle choices. It requires regular medical treatment and follow-up to ensure one can lose weight effectively and safely," he shares, adding that obesity results from a combination of genetic, metabolic, behavioural, and cultural factors.
Obesity is associated with more than 200 diseases affecting almost every organ in the body. Without proper medical attention, obesity could lead to potentially life-threatening conditions such as coronary heart disease, stroke, diabetes, and hypertension. It is also linked to other less well-known conditions like obstructive sleep apnoea, fatty liver disease and even depression and eating disorders, which can further negatively impact on one's quality of life.
As a member of the SKH Weight Improvement Therapy and Complete Health (SWITCH) programme since 2018, Dr Chua has journeyed closely with patients with obesity and learnt first-hand of their struggles, both physical and emotional.
Putting up with unkind remarks, feeling demoralised when hitting a weight loss plateau as well as facing animosity and isolation when embarking on positive lifestyle changes – these are all par for the course for Dr Chua's patients. This is why he dedicates a significant proportion of the first consultation to understanding the patient as a whole before recommending a management plan, taking into consideration at all times his or her preferences and unique circumstances. This plan may include referrals to SWITCH's multidisciplinary team of dietitians, physiotherapists, and psychologists.
For some, lifestyle changes are particularly important for long-term maintenance of weight loss – a notable example being after undergoing bariatric surgery.
"I find it useful to explain this through the 'weight loss pyramid', in which lifestyle interventions are at the base of the pyramid and therefore form the foundation of successful long-term weight loss, and on which other forms of weight loss treatment can be built upon," explains Dr Chua.
Dr Chua advises that the key to maintaining weight loss is to make small, sustainable changes and celebrate small goals which may not be directly related to weight. For example, if you are used to drinking coffee with sugar daily, your initial goal could be to switch to coffee with less sugar, then to unsweetened coffee after a few weeks. Likewise, for physical activity, you could start with small steps, such as alighting two bus-stops from home and walking the remaining distance or walking home from the MRT station rather than taking a bus.
"If you can achieve the 'small' goals which you set for yourself, congratulate yourself and strive to maintain them, possibly setting another higher goal for the near future. But, if you find yourself going back to old habits after a few weeks, please don't be discouraged and know that you can always start again," advises Dr Chua.
That said, lifestyle interventions may not achieve sufficient weight loss. This is due to "a fat mass set point which our bodies innately strive to maintain", which can lead to a weight plateau (period of little change) after initial weight loss.
Lifestyle modifications also include being conscious of one's eating habits when one is feeling emotional. According to SKH senior psychologists Audrey Bay and Sheryne Seah, also with the SWITCH programme, the majority of their patients' weight issues stem from emotional eating and/or negative self-perception.
"Patients have shared that they tend to turn to food to alleviate unpleasant emotions stemming from work stress, caregiver stress, sadness or disappointments; or celebrate pleasant emotions from happy occasions such as receiving a promotion," reveal the psychologists.
For tips on how to cope with emotional eating – check out this HealthXchange article.
While the occasional indulgence is fine, it is when it becomes a regular habit that it can become detrimental to one's health. When patients struggle with body image issues or low self-esteem, they may avoid exercising outdoors or attending family gatherings for fear of being shamed by others. These emotional and psychological factors can be roadblocks to successful weight loss.
It can lead to unhealthy weight control practices, such as crash dieting or consuming supplements which may not be medically approved. Beyond willpower, individuals may need medical intervention and sound advice on nutrition and exercise.
Dr Chua firmly believes that rather than focusing exclusively on losing weight, attention should be centred on maintaining good health regardless of your weight. The rationale for treatment of obesity is to reduce weight-related complications, rather than for aesthetic reasons. Therefore, people who already have weight-related complications as well as those with more severe degrees of obesity should consider seeking professional help early.
In patients with more severe degrees of obesity and those with weight-related complications such as diabetes, particularly if poorly controlled, Dr Chua may recommend medications, endoscopic therapies, and bariatric surgery as appropriate.
Taking prescribed medications may be helpful if the patient's BMI exceeds 30kg/m2 with at least one weight-related complication, and the patient has failed to lose weight through lifestyle changes. Medications such as phentermine, topiramate, orlistat, liraglutide, semaglutide and bupropion naltrexone work in different ways to aid weight loss. For example, phentermine leads to appetite suppression while orlistat reduces absorption of fat from the intestines. Apart from weight loss, semaglutide has additional clinical benefits in patients with diabetes, cardiovascular conditions, and chronic kidney disease.
Patients must be committed to proper follow-up to determine if the course of treatment is effective, as well as whether there are any significant side-effects. If it is ineffective or there are significant adverse effects, a change of medication might be recommended. If the medication proves to be effective, it remains essential to continue lifestyle changes to maintain and keep off the extra weight.
In more extreme cases of obesity, where BMI levels exceed 37.5 kg/m2 or 32.5 kg/m2 with at least one weight-related complication, bariatric surgery can be considered. The two main procedures are sleeve gastrectomy and gastric bypass. Bariatric surgery can lead to remission of weight-related complications such as diabetes, allowing patients with diabetes to stop their medications yet maintain acceptable glycaemic control.
As with medications, bariatric surgery is not a quick fix for obesity. Patients must be committed to making long-term dietary changes and taking vitamin and mineral supplementation. Otherwise, weight regain is inevitable and nutritional deficiencies may ensue.
Endoscopic therapies bridge the gap between pharmacotherapy and surgery as they are less invasive than surgery and are reversible. The two main forms are endoscopic balloon insertion and endoscopic sleeve gastroplasty (ESG). Endoscopic balloon involves insertion of a balloon into the stomach – this shrinks the capacity of the stomach, leading to a reduction in appetite. ESG involves suturing the stomach through an endoscope, which also reduces its volume and slows the rate of gastric emptying. Thus, the patient not only has decreased appetite, but also feels full for longer.
Whatever the treatment plan chosen, it is important to be realistic and not expect instant results. "Regardless of the initial treatment plan and weight loss response, long-term follow-up is essential," advises Dr Chua, as "weight management is like a marathon rather than a sprint." Taking that first step is the all-important start of one's journey to lifelong good health.
Overweight is defined as Body Mass Index (BMI) of ≥25 to <30 kg/m2, while obesity is defined as BMI of ≥30 kg/m2. For Asians, high-risk BMI is denoted by a lower BMI threshold of ≥27.5 kg/m2, due to our higher body fat and higher risk of diabetes and cardiovascular disease compared to Caucasians.
Nearly 1 billion in the world lived with obesity in 2020 – This is approximately one in seven people.
In Singapore, the percentage of people living with obesity has been steadily climbing from 8.6% in 2017 to 10.5% in 2019-2020 and to 11.6% in 2021-2022. However, this is based on a BMI cut-off of 30kg/m2.
If we use the high-risk BMI cut-off for Asians, which gives a more accurate representation of the magnitude of the problem of obesity in our society, the percentage of Singapore residents with high-risk BMI has increased from 18.7% in 2017 and 20.7% in 2019 – 2020 to 22.3% in 2021 – 2022. This translates to approximately one in five Singapore residents – an alarming statistic.
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