Fat-shaming obese people will not help them lose weight. Here is what experts want you to know

SINGAPORE — Sheer laziness, lack of discipline and overindulging in one too many sweet treats and junk food.

People living with obesity are no strangers to receiving loaded comments about their weight, and being told that obesity is a failure on their part and that it can be reversed if they just “try harder”.

Is it really that simple?

Research now shows that obesity — recognised as a chronic disease — is far more complicated than people think. And fat shaming is unlikely to help obese individuals achieve and maintain a healthy weight. 

Various factors, some of which are beyond a person’s control, can affect body weight and how the body retains fat.

Dr Yvonne Lim, a consultant at the National University Hospital’s (NUH’s) division of paediatric endocrinology and the Youth Lifestyle Change Clinic, said that a common misconception about obesity is that individuals lack willpower or become obese due to bad lifestyle choices, but it is not that straightforward.

A person is considered morbidly obese here if his or her Body Mass Index (BMI) exceeds 37.5, or if it is 32.5 with an obesity-related health condition.

TODAY looks at this health issue, why achieving and maintaining a healthy weight is so challenging for some people, and what can be done to treat and manage obesity more effectively.

WHAT IS THE OBESITY TREND IN SINGAPORE?

In 1992, just one in 20, or 5.1 per cent, of the adult population aged 18 to 69 was considered obese.

By 2010, the figure doubled to 10.8 per cent before dropping to 8.7 per cent in 2017, based on findings from the National Population Health Survey.

The young are not spared. In 2017, 13 per cent of Singapore children are considered overweight, compared to 11 per cent in 2011.

At the National University Hospital (NUH), the number of children and teenagers undergoing its paediatric weight management programme has almost tripled in the last five years, from 41 cases in 2014 to 154 cases for the period from July 2018 to July 2019. 

WHY IS BMI FOR OBESITY LOWER IN SINGAPORE?

Around the world, obesity rates have tripled in the last 40 years, the World Health Organization (WHO) reported.

WHO defines someone as obese when the person has a BMI of above 30; a person with a BMI of above 40 is considered morbidly obese.

For Asians, however, the cut-off is lower. A person with a BMI of 27.5 and above is considered obese. Those with a BMI of 37.5 and above, or 32.5 and above with associated obesity-related health conditions, are considered morbidly obese.

Dr Sonali Ganguly, a senior consultant at Singapore General Hospital’s (SGH’s) department of endocrinology, said that Asians tend to develop obesity-related metabolic complications at a lower BMI. Metabolism is the process by which the body converts food and drink into energy.

This explains why the Asia-Pacific classification of BMI has a lower cut-off for overweight and obese categories.

WHAT CAUSES SUCH EXTREME WEIGHT GAIN?

Like many diseases, several causes can contribute to rising obesity rates. Some of them are beyond a person’s control or choice. They are:

1. GENETIC FACTORS

Genes may affect the amount of body fat that one stores and where that fat is distributed.

Dr Lim Chin Hong, director at the Lifestyle Improvement and Fitness Enhancement (Life) Centre in SGH, said that genetics may also play a role in how efficiently the body converts food into energy, how the body regulate appetite and burns calories during exercise.

Dr Baldwin Yeung, an associate consultant at the department of general surgery in Sengkang General Hospital (SKH), said that historically in Asia, people live in relatively resource-poor environments and “natural selection” has given an advantage to these people to store fat better when food was scarce.

Although there is an abundance of food now, these fat-storing genes may be still at work.

2. PRENATAL FACTORS, INFANCY AND CHILDHOOD HABITS

A new report released in May by the National Healthcare Group in Singapore showed that seven in 10 children who are overweight at the age of seven would likely go on to become obese as adults.

Dr Yvonne Lim of NUH referred to the Gusto study, which is a birth-cohort study that looks at how pregnancy and early childhood influence the health and development of women and their children.

It found that mothers’ weight and health status during pregnancy may affect their child’s weight later in life.

Risk factors that may increase a child’s risk of obesity include:

• Maternal obesity before pregnancy
• Mother’s excessive weight gain during pregnancy
• Gestational diabetes during pregnancy
• Short duration of breastfeeding
• Starting solid-food feeding before the age of four months
• Faster eating rates, where children do not chew longer before swallowing and end up eating more

3. HORMONAL CHANGES

Changes in hormones associated with ageing or pregnancy, not getting enough sleep or getting too much sleep — all these can increase one’s appetite, incite cravings for foods high in calories and reduce metabolism, Dr Lim Chin Hong of SGH said. This makes it harder to keep excess weight off.

4. MEDICATIONS

Anti-depressants, diabetes medication, steroids and beta blockers for high blood pressure can lead to weight gain.

5. LIFESTYLE AND A FOOD-CENTRED CULTURE

In Singapore, access to high-calorie and processed foods, a culture of dining out, and people having more sedentary time might have contributed to rising obesity rates.

Furthermore, the national identity and pride is often tied to food, which tends to be at the centrepiece of celebrations and festivals, Dr Lim Chin Hong said.

6. ARTIFICIAL LIGHTS

Exposure to artificial light, from electric light bulbs and electronic screens, may alter the body’s inner circadian rhythm — generally known as the sleep-wake cycle that regulates physical, mental, and behavioural changes.

Some researchers believe that this may alter metabolism, which could contribute to rising obesity rates across industrialised nations, Dr Yeung said.

WHY SHOULD OBESITY BE TAKEN SERIOUSLY?

Dr Yeung said it is important for the public to recognise that obesity is a disease that causes harm to the patient. People who struggle with obesity also tend to have other obesity-related medical conditions.

“People can die from obesity,” Dr Yeung warned.

He estimated that about a third of patients with obesity seen at SKH have Type 2 diabetes; about one in five have high blood pressure; and a quarter of them have obstructive sleep apnoea — a sleep disorder which causes breathing to stop involuntarily for brief periods of time during sleep. 

Dr Lim Chin Hong, who is also a consultant at SGH’s department of upper gastrointestinal and bariatric surgery, said that almost all patients with BMI exceeding 32.5 will have obesity-related health conditions.

Last year, SGH’s weight management programme saw more than 16,000 patients, half of whom have obesity-related diseases.

They range from “obvious” conditions such as diabetes and heart attacks to “silent” diseases such as fatty liver, gastric reflux, irregular menstruation, subfertility, erectile dysfunction and varicose veins.

WHY CAN’T OBESE PERSONS KEEP THEIR WEIGHT DOWN?

While preventive measures may be helpful for some people, the experts said that weight loss can be challenging for those who are already obese due to a person’s “set point” for weight.

Dr Lim Chin Hong said: “Our body is biologically and genetically pre-determined to weigh within a certain weight range. Just as one has no control over his height or eye colour, an individual similarly has no control over what his weight set point will be.”  

Dr Yeung said studies have shown that prolonged dieting rarely resets a person’s “set point”, explaining why treating obesity and maintaining weight loss with dieting alone may be an uphill task.

WHAT OTHER CHALLENGES DO OBESE PERSONS FACE?

Even as experts deal with the physical health aspects of obesity, Dr Lim Chin Hong said that the greater challenge lies in managing its psychological and social impact.

Dr Yeung said research shows that stigma can make it more difficult for overweight people to lose weight and keep it off.

At the Sengkang Weight Improvement Therapy and Complete Health (Switch) Centre in SKH, a survey of patients found that almost all of the obese patients surveyed blamed themselves for their weight problems, he added.

Unrealistic expectations of how much weight they should lose can also sabotage their weight-loss efforts. 

Dr Yeung said that in the same survey at the Switch Centre, a majority of those with obesity believed that they need to lose more than 20 per cent of their weight to reap health benefits.

In reality, just a weight loss of 5 per cent to 10 per cent can improve health.

WHAT TREATMENTS ARE AVAILABLE?

Dr Sonali of SGH said that lifestyle modifications with diet and exercise remain the cornerstone of obesity management.

When these measures are inadequate, other options may include:

1. Medications approved for obesity management. They can be considered in patients with a BMI of above 30 or BMI of 27.5 with at least one obesity-related medical condition.

2. Bariatric surgery, or surgery that achieves weight loss by restricting the amount of food the stomach can hold, is reserved for patients with BMI above 37.5 or BMI of 32.5 with at least one obesity-related medical condition.

3. Intra-gastric balloon is a non-surgical option that involves inserting a soft silicon balloon into the stomach through the mouth to make the person feel full sooner.

4. Endoscopic sleeve gastroplasty is a newer type of weight-loss procedure that reduces the size of the stomach using an endoscopic suturing device without the need for surgery. Last year, SGH performed the first three cases of this in Singapore, Dr Lim Chin Hong said.

HOW EFFECTIVE ARE WEIGHT-LOSS PROCEDURES?

Not all obese patients are suitable for surgery, but the experts said that those who have successfully undergone bariatric surgery will lose 25 to 30 per cent of their initial weight. Most maintain their weight loss over time. 

More importantly, the patients showed significant improvements or even reversed their obesity-related conditions, which could have led to potential life-threatening complications if left unchecked.

Dr Lim Chin Hong said that 80 per cent of patients had their diabetes cured after bariatric surgery, and remain cured after five years.

Dr Yeung said: “A recent study also showed a lower risk of adverse cardiovascular events in patients whose obesity was treated with surgery.”

Rather than leave it as a “last resort” option, Dr Yeung feels that the option of bariatric surgery should be brought up earlier for people struggling with obesity and other obesity-related medical conditions, along with other weight management options.

He said: “As a society, we need to recognise that obesity is a disease and that weight management for this group of people is not for cosmetic reasons.”