obesity reviews doi: 10.1111/obr.12092 Asia Obesity prevention and management: Singapore’s experience L. L. Foo1, K. Vijaya1, R. A. Sloan2 and A. Ling2 1Youth Health Division, Health Promotion Summary Board, Singapore; 2Adult Health Division, Singapore’s obesity prevalence among adult Singapore residents aged 18–69 Health Promotion Board, Singapore increased from 6.9% (2004) to 10.8% (2010). Among school-going children, the prevalence of overweight and severely overweight (body weight > 120% standard Received 14 August 2013; accepted 15 weight for height) increased from 1.4% (1976) to 12.7% (2006) for primary 1 August 2013 students, and 2.2% to 15.9% for primary 6 students. Fundamentally, obesity is a function of excess energy intake (food consumption) and insufficient energy Address for correspondence: Dr A Ling, Adult expenditure (physical activity). In 2010, about 40% did not have sufficient physi- Health Division, Health Promotion Board, 3 cal activity, and about 60% consumed excess energy. For students in the main- Second Hospital Avenue, Singapore 168937. stream schools, only a fifth consumed at least two servings of fruits and vegetables E-mail: [email protected] every day, and a tenth were physically active for at least 60 min on 5 or more days a week. From a public health perspective, the most powerful levers for influencing population health lie in interventions that make healthy living convenient and an unconscious choice by targeting the social and environmental context. Recogniz- ing this, the Health Promotion Board has in recent years made a strategic shift away from just public education campaigns aimed at individual behaviours, to focus on creating a ground-up social movement to enable and empower individ- uals to live out a healthy lifestyle. Keywords: Life-cycle approach, obesity prevention and management, Singapore. obesity reviews (2013) 14 (Suppl. 2), 106–113 account for more than 60% of all deaths (1). Obesity is a Background risk factor for many of these disease conditions. Since its independence in 1965, Singapore has undergone a In Singapore, obesity prevention and management efforts rapid transformation. With economic progress, improve- are largely coordinated by the Health Promotion Board ments in housing and sanitary conditions, increased (HPB), a statutory board under the purview of the Ministry availability of potable water, and the implementation of a of Health (MOH). The HPB leads national health promo- comprehensive vaccine and disease surveillance programs, tion and disease prevention programs to help Singaporeans Singapore underwent an epidemiological transition from a attain optimal health throughout life. pattern of high prevalence of infectious diseases associated with malnutrition and poor environmental sanitation to Extent of overweight and obesity in Singapore one featuring a high prevalence of chronic and degenerative diseases associated with more affluent lifestyles. Today, The prevalence of obesity (body mass index [BMI] ≥ 30 cancer, cardiovascular disease, and diabetes mellitus are kilograms per square meter [kg m−2]) among Singapore among the top 10 diseases affecting Singaporeans, and they residents aged 18–69 has increased steadily from 1992 to 106 © 2013 The Authors. Obesity Reviews published by John Wiley & Sons Ltd 14 (Suppl. 2), 106–113, November 2013 on behalf of the International Association for the Study of Obesity. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. obesity reviews Obesity prevention and management in Singapore L. L. Foo et al. 107 Table 1 Prevalence of overweight and obesity among Singapore personal choice but is also affected by environmental and residents aged 18–69 from 1992–2010 social factors (9). Singaporeans consume more high-energy Condition 1992 1998 2004 2010 and low-nutrient food partly because it is produced, priced and marketed accessibly and attractively. By the same Overweight (BMI ≥ 25 kg m−2) 21.1% 24.4% 25.6% 29.3% token, the physical activity level is not as high as it should Overweight (BMI ≥ 30 kg m−2) 5.1% 6.0% 6.9% 10.8% be partly because of the way society is now organized, including building designs that encourage the use of elevators rather than stairs, the widespread reliance on cars, and the overwhelming demands of studies and work, 2010, and it currently stands at 10.8% (2). The prevalence among others. of obesity is higher in males (12.1%) compared with females (9.5%). Among ethnic groups, obesity is most Key obesity prevention and prevalent in Malays (24.0%), followed by Indians (16.9%) management strategies and Chinese (7.9%). While Singapore’s obesity rate is lower than that in many developed countries (3), it is still With obesity originating early in life, the HPB has adopted a a concern, as 40.1% of the population is overweight life-cycle approach to the issue. This approach is anchored (BMI ≥ 25 kg m−2) (see Table 1). on key strategies of obesity prevention and management, Obesity starts in childhood and tends to persist in adult- including health-promoting public policies and guidelines; hood. The estimate is that approximately three-quarters of capacity building and empowerment; ecosystemic changes children with obesity will continue to suffer from the con- to make the healthier choice the preferred choice where dition during adulthood (4). The overweight and severely people live, study, work and play; and collaborative part- overweight prevalence in Singapore has increased over the nerships that bring together the public, the people and the past few decades. In 1976, the prevalence of overweight private sectors of Singapore. and severely overweight was 1.4% for primary 1 students, and it increased ninefold to 12.7% by 2006. This was Development of health-promoting public defined as body weight more than 120% of the standard policies and guidelines weight for height, using weight-for-height norms (5). Simi- larly the overweight and severely overweight prevalence Guidelines on nutrition and physical activity for the popu- was 2.2% for primary 6 students in 1976, and it increased lation have been developed by the HPB to provide the public sevenfold to 15.9% in 30 years. The prevalence of over- and professionals with practical information on the nutri- weight and severely overweight among schoolchildren in tional needs and physical activity recommendations in the mainstream schools from primary to pre-university levels in different life stages. As part of the broader effort to prevent 2011 was 11% based on BMI-for-age norms (6). and manage childhood obesity, the HPB is developing guide- Energy intake through food consumption and energy lines for food advertising directed to children. Evidence expenditure through physical activity are two major factors shows that food marketing influences children’s food influencing weight gain. In 2010, about 6 in 10 Singapore preferences, purchase requests to parents, food choices residents aged 18–69 consumed excess energy, and the and consumption patterns (10–14). In Singapore, advertise- average intake of calories and fat have increased by 10 and ments are guided by the Singapore Code of Advertising 20%, respectively, since 2004 (7). These increases may be Practice (SCAP), which is administered by the Advertising the result of an increase in meals consumed out of the Standards Authority of Singapore (ASAS). Whereas the home. In terms of physical activity, 4 in 10 Singapore SCAP currently regulates the types of advertisements that residents aged 18–69 did not meet the recommended can be directed to children, there is no specific regulation of minimum of 30 min of moderately intense activity on 5 or children’s exposure to unhealthy food advertisements other more days a week in 2010 (2). For students in the main- than discouraging confectionery and snack foods as a stream schools from primary to pre-university levels, the replacement for main meals (15). In line with the World Students’ Health Survey 2009 found that only a fifth con- Health Organization (WHO) recommendation of restricting sumed at least two servings of fruits and vegetables every food marketing to children (16), Singapore is reviewing its day and a tenth were physically active for at least 60 min standards for advertising directed to children of food and on 5 or more days a week (8). These findings showed that beverage products high in fat, sugar or salt. An online public more can be done to promote healthy eating and regular consultation exercise was conducted in late 2012 to gather physical activity among the general population in Singa- public feedback on the proposed strengthening of guidelines pore. This would require that Singapore move beyond on food advertising directed to children. Responses from the health education at the individual level to promote health public overwhelmingly supported introduction of restric- at an ecosystemic level, as obesity is not just a matter of tions on food advertising to children. The MOH, the HPB © 2013 The Authors. Obesity Reviews published by John Wiley & Sons Ltd on behalf of the International Association for the Study of Obesity 14 (Suppl. 2), 106–113, November 2013 108 Obesity prevention and management in Singapore L. L. Foo et al. obesity reviews and the ASAS are currently working out the details of opmental to the preschool years, thereby helping to give the guidelines for food advertising directed to children (17). these children a healthy head start in life. These resource The HPB is also leading an expert committee to update the guides are also available on the HPB website (21–23). In Clinical Practice Guidelines (CPG) for obesity, which will addition, the HPB conducts workshops and culinary train- provide guidance to health professionals on the manage- ing to equip parents and caregivers with knowledge and ment of obesity in Singapore.