The Obesity Issue in Singapore
Abstract
Globally, 1 in 8 people are obese1. This has given cause for concern, especially in the developed world. Despite having the means to nourish oneself properly, the allure of less healthy food choices proves formidably tempting. Obesity hence remains an acute problem in the developed world. Singapore is not exempt from this phenomenon, with 30% of Singaporeans classified as overweight, and more than 10% of Singaporeans as obese2.
Why, then, is this the case? In a country with compulsory military conscription, mandatory physical fitness tests in schools and various health intervention plans, such figures are worrying. Coupled with an ageing population, the additional strain obesity-related issues are set to place on Singapore’s healthcare system is grossly unwelcome. This article will explore the possible causes of obesity in Singapore, examine and review the current measures in place to tackle obesity, and suggest measures that we can adopt to curb this worrying trend.
1 The current state
1.1 Causes of obesity in Singapore
Genetic factors contribute to obesity by influencing the function of metabolic pathways in the body, along with the regulation of appetite centers3. This is closely linked to maternal and paternal nutrition and lifestyle factors4. Obesity can also result from modifiable lifestyle factors such as excessive intake of foods that are high in fats and sugars, as well as lack of physical activity5.
Certain regional characteristics have been found to contribute to the rise of obesity in Southeast Asia. The rapid growth in large food retail companies, such as fast-food outlets and 24-hour food establishments, along with a unique eating-out culture in Southeast Asian countries has played a significant role in shaping our eating habits6. This is especially so where a significant portion of the urban population regularly consumes foods from the informal food sector. Such meals, however, often are energy-dense, high in fat, sugar or salt, and detrimental for individuals who seek healthier choices when dining out7.
The Covid-19 pandemic has only worsened the obesity phenomenon. From 2017-2021, the proportion of students who were overweight in schools increased from 13% to 16%8. The implementation and mainstream adoption of ‘work from home’ for office workers and ‘home-based learning’ for schools has added another element of sedentism into our lives. For a period, gone were the days when children could have their daily dose of catching during recess. Instead, confined to a desk-chair in front of a screen for hours, children were denied a key opportunity to keep active while having fun. Of concern, the obesity rate has remained above 10%9 of the population since the pandemic, and has not decreased.
Obesity rates amongst the three dominant races in Singapore are notably unequal. An eye-opening study by Chay et al (2022)10 revealed that Indians and Malays were three to four times more likely to be obese than their Chinese counterparts. Worryingly, obesity among adults aged 30 to 59 years was about 12%, almost double that of those aged 18 to 29 years (6.6%)11. These statistics suggest that obesity has afflicted Singapore unequally, and is possibly attributable to the differing dietary practices among different ethnic groups12.
These multifactorial causes of obesity present a challenge for policymakers in Singapore to overcome. The unequal prevalence of obesity between various segments of the population compounds the difficulty in creating effective measures to combat the rise of obesity. Genetic factors are near impossible to control. It goes without saying that shaping lifestyle choices through nutrition and physical activity become of ever more importance.
1.2 Causes of obesity in Singapore
The adverse impact of obesity can be seen on multiple levels. On an individual front, there is extensive literature on the causal role of excess adiposity on obesity-related diseases: diabetes mellitus, dyslipidemia, hypertension, fatty liver disease, cardiovascular diseases and so on13. On a national level, the predicted total medical expenditure attributable to obesity and overweight related health issues was estimated to be SGD 178 million, representing 1.6% of Singapore’s total healthcare expenditures in 2019. This represents an additional burden on the already increasing healthcare expenditure, one which can be mitigated by more stringent measures in fighting obesity.
2 Existing measures
Singapore has undertaken various interventionist policies to curb the rise of obesity. These policies can be split into regulatory nutritional measures and individual behavioral measures. Whilst laudable, obesity rates still have been increasing gradually, signifying that current measures may be insufficient to keep Singapore in line with our national targets for obesity15.
2.1 Shaping Consumer Drinking Habit
To inform consumer choice when it comes to healthier consumption choices, Nutri-Grade labelling for beverages sold in Singapore in pre-packaged form was mandated from December 2022. A year later, these requirements were extended to freshly-prepared beverages for sale, which include bubble tea stores and freshly blended smoothies. Companies now have to follow strict regulations and specifications for the Nutri-Grade mark on their beverages.
The Nutri-Grade Grading System16 grades drinks (in a typical Singaporean fashion) from ‘A’ to ‘D’, along a sugar content and saturated fat content scale. ‘A’ grade drinks have the least sugar and saturated fat content, whilst ‘D’ grade drinks have the highest. The Healthier Choice Stamp is accorded to drinks with an ‘A’ or ‘B’ grading17. Nutri-Grade ‘C’ and ‘D’ drinks must be labelled with the Nutri-Grade mark on the front of the package.
This is a welcome change that helps consumers make informed choices. High sugar intake has an adverse effect on individual health, with links to obesity and diabetes. Singaporeans consume an average of 58g of sugar daily, of which more than half comes from beverages18. Instead of merely a Healthier Choice label, Singaporeans are now confronted with the sugar level of their drinks on an all too familiar scale, making it impossible for consumers to escape how unhealthy a certain beverage is.
However, salience alone is unlikely to be able to command a widespread influence on all consumers, compelling them to consume healthier beverages. This will especially be the case for consumers who habitually consume sugary drinks such as heavily sweetened coffee or bubble tea. ‘Information’ is but one of three core elements of choice architecture which can influence changes in human behaviour19, the others being availability of products and size of products. To fully leverage Nudge Theory to influence consumer choice, the Health Promotion Board can explore further measures restricting availability of Sugar-Sweetened Beverages (SSBs) or implementing regulations on the size of these beverages served. This strengthens the case for adopting a ‘Soft Drinks Levy,’ as will be explored in the policy recommendations in the next section.
Further, mere information on sugar consumption may not translate to a stronger understanding of the detrimental effects of heightened sugar consumption on our bodies20. Public awareness must be raised on the exact amounts of sugar one can healthily take daily. The World Health Organisation recommends reducing the intake of free sugars to less than 10% of one’s everyday energy intake21. On average, the reference intake for total sugars is 90g a day, which includes 30g of free sugars22. Given the difficulty in tracking sugar intake in food, this increases the importance of consumer awareness in the beverages they consume.
2.2 Promoting an Active Lifestyle
In a bid to combat sedentarism, the government has introduced measures to promote an active lifestyle. What began as a trial of a ‘Steps for Good’ challenge in schools transformed into the Healthy 365 Mobile Application, which seeks to motivate Singaporeans to adopt healthy habits and lifestyles through gamification. Features of the application include a Meal Log, a daily steps tracker, various health challenges one can embark on and informative health resources regarding eating healthy that one can peruse. “Healthpoints” can be earned by logging meals, clocking steps or purchasing foodstuffs with the Healthier Choice symbol23. These Healthpoints can then be used to redeem vouchers for supermarkets, public transport and other retailers.
Embedded in the Healthy 365 Application is the well-known National Steps Challenge, which all individuals above the age of 17 are eligible to register for. The Health Promotion Board set up various roadshows and advertisements across the country, along with giving out free health trackers to incentivise Singaporeans to get on board on the challenge. An interesting study revealed that for the third iteration of the National Steps Challenge (otherwise known as NSC 3), over 14% of the adult population in Singapore actively participated in the first 7 months24. However, a substantial decline in engagement was observed over time, with less than a third of participants recording activity by the end of the challenge period25. While a substantial and clinically meaningful increase in step count was achieved during the challenge period, whether or not this increase lasted beyond the challenge remains unknown. It can only be hoped that Singaporeans incorporate an active lifestyle beyond the timeframe of the challenge.
2.3 Intervention in Schools
The Healthy Meals in School Programme26, first promulgated in 1992, provides food service guidelines for canteen vendors in schools, such as a list of beverages that are permitted to be sold, a supplier listing directory for the sourcing of healthy ingredients and healthier recipe ideas for vendors to use. These guidelines have seen the phasing out of unhealthy foods in certain school canteens, such as deep-fried chicken. However, the availability of healthy foods in a canteen may be insufficient in shifting the tastes and food preferences of children towards a healthier diet.
The provision of healthier foods may not necessarily translate to their consumption. In a pilot study done in primary schools in Singapore27, children revealed that they would either give away the fruits and vegetables provided to them to their friends or throw them away if they were not to their liking. Despite knowledge of healthy eating amongst primary school children, along with the availability of healthy food and incentives by the parents and school, diets of primary school children (aged 6-12), were found to be lacking in fruits, vegetables, whole grains, and high in sodium and sugar28.
The abysmal diet of primary school children is a worrying sign that current interventions in school are largely inadequate in cultivating healthy practices amongst Singaporean children. The importance of diet in children, which could have far reaching effects into adulthood, may justify a more radical approach in ‘urging’ a good diet, in a bid to bring down the worryingly heightening obesity rates in the Singaporean student population.
3 Policy Recommendations
Looking beyond our borders, it is worth examining what other countries have been doing to fight the obesity phenomenon, to find measures which Singapore can consider adopting to complement our current strategy.
3.1 Taking Bolder Steps in Influencing Consumer Choices
Singapore can consider bolder regulatory intervention in curbing the consumption of Sugar-Sweetened Beverages (SSBs). The United Kingdom’s Soft Drinks Industry Levy29 has removed the equivalent of over 45,000 tons of sugar from soft drinks since its introduction in 2018. The levy is a tiered one: for drinks with 5-7g of sugar per 100ml, 18p tax per litre is charged; for drinks with 8g or more sugar per 100ml, a tax of 24p per litre is levied. This has had a pronounced impact on the sale of sugary beverages, with the average sugar content of retailer and manufacturer branded drinks subject to the Soft Drinks Industry Levy decreasing by 46% between 2015 and 2020.
By adding a financial disincentive on the production of SSBs, we would likely see a drop in the sugar content of the sweetest beverages out there, as they become subject to a levy. This would complement the current Nutri-Grading on healthier drinks, presenting them as more attractive alternatives for consumers to drink, and producers to produce. At the baseline, sweet drink producers would be incentivised to create less sweet alternatives to popular SSBs, which could eventually replace unhealthier options on most Singaporean’s palates.
Such a levy would also work hand in hand with the current ban in Singapore on the advertisement of SSBs, which came into effect in 2019. Over the short span of 5 years since the ban came into effect, the average sugar content in newly launched products decreased by 38% in instant coffees, 24% in soft drinks, 21% in iced coffees and 18% in juices30. A levy could further the effects of this advertisement ban beyond pre-packaged drinks listed above, but also for drinks made on the spot, such as bubble tea and freshly made juices.
The imposition of levies may induce unintended consequences, such as the rise in artificially-sweetened beverages. Research has shown that artificially-sweetened beverages have had increased risk on certain health outcomes31. However, regulated sweeteners are considered safe and an acceptable alternative to using sugar32. Artificially-sweetened beverages will be a healthier and more desirable option compared to their sugary-beverage counterparts, allowing consumers to enjoy their beverages without compromising on taste.
3.2 Empowering Singaporeans to Take Care of their Health
Introduced in 2008, Japan’s ‘Metabo Law’ requires annual waist measurements for people aged 40 to 74, with the aim of preventing obesity and reducing the risk of other diseases. At its core, employers and local governments were financially encouraged to keep their ‘metabo’ rates down, or face fines33. The Japanese Government followed up with a nationwide screening and lifestyle intervention programme for abdominal obesity, involving more than 100 million people. These measures were proven to yield a substantial and sustained improvement in abdominal obesity and reversal of metabolic syndrome34. Japan’s obesity rates are now one of the lowest in the developed world, at 3.7% — evidence that it is possible to bring obesity rates down through the combined efforts of the government, companies and individuals35.
Despite its effectiveness, the introduction of a ‘Metabo Law’ may prove culturally insensitive in Singapore. The social phenomenon of “fat-shaming”36, along with the stigma against obese people, may potentially contribute to an unwelcoming and discouraging climate for those trying to lose weight. This may prove detrimental to individual well-being. Rather, Singapore can consider adopting certain other aspects of the Japanese approach, namely nationwide screening and lifestyle intervention for abdominal obesity.
Healthier SG is a recent initiative implemented by Singapore, encouraging Singaporeans to register with General Practitioners and signaling an emphasis on preventive healthcare. This aims to develop a closer relationship between doctor and patient. In many ways, this seems to mirror the Japanese approach in early lifestyle intervention, with obesity acknowledged as one of the medium-term goals to be tackled in the next three to ten years37. Given the recency of this initiative, the longer-term impacts on the obesity rate remain yet to be seen. Nevertheless, the unfamiliarity with obesity management among healthcare providers remains a hurdle that Singapore has yet to overcome38. It can only be hoped that with time, a renewed emphasis on bringing obesity levels down would bear fruit.
3.3 Stricter Intervention in Schools
Arising from a pressing need to combat childhood malnutrition in the post-war years, the School Lunch Program Act was passed by the Japanese Government in 1954 to provide safe and nutritious school lunches for all students. As of May 2021, 99.7% of all public elementary schools and 98.2% of all junior high schools provide school lunches39. School kitchens prepare healthy meals which are then served by the students to their batchmates, incorporating food and nutrition education in the process. This has been accredited for improving the total diet quality of Japanese students, particularly in respect of the intake of important vitamins and minerals in Japanese children40.
Schools in Singapore could consider adopting such an approach. While costly and logistically difficult to implement, a central kitchen puts schools in direct control of the nutrition of students. While this comes at the cost of choice, inculcating healthy eating habits from young could reduce the chances of obesity in the long term41. Nutritionists and sports scientists could plan the dietary intake of children, crafting meal plans for different age groups, with reference to Health Promotion Board healthy eating initiatives. Inspiration could be drawn from the cookhouse concept used by the Singapore Armed Forces in camps. This would improve nutrition for children in their school-going years, fostering healthy habits from young and decreasing the likelihood of childhood obesity.
4 Conclusion
In view of the adverse impacts of obesity on individual well-being and nationwide medical costs, Singapore should take more proactive measures in improving the nutrition of its citizens, encourage weight loss and promote a healthier lifestyle. This is especially so in schools, where good eating and lifestyle habits may be more easily cultivated from young. For adults, more interventionist approaches can be explored to empower Singaporeans to look after their own health, be it in shaping lifestyle habits or regulating the production of unhealthy beverages. Singapore must endeavour to go beyond educating people on the adverse impacts of obesity, to constantly nudge and push Singaporeans to take ownership of their own health and well-being.
A thus far unexplored facet of countering obesity has been advances in weight-loss drugs, which have the potential to aid in the fight against this seemingly irreversible trend of rising obesity. Singapore has recently approved Semaglutide42, a medication to treat obesity and type 2 diabetes. But lifestyle modifications remain paramount to successful weight management, with weight gain post treatment being common43. Furthermore, one’s body can develop tolerance to the drug, resulting in reduced effectiveness of weight-loss drugs44. Weight-loss drugs alone are hence not the magic solution for obesity.
Healthier SG presents a breath of hope for preventive healthcare in obesity, along with resources and individualised care plans that could aid those already struggling with weight. It remains yet to be seen how effective Healthier SG will be in curbing the rise of obesity in Singapore. We cannot afford to be complacent that governmental initiatives will miraculously solve this issue. In the end, it will be up to us, the everyday Singaporeans, to play our part in taking care of our own bodies.
Footnotes
1 World Health Organisation, ‘Obesity and Overweight’ <https: data-preserve-html-node="true"//www.who.int/news-room/fact-sheets/detail/obesity-and-overweight> accessed 23 November 2024.
2 Health Promotion Board, ‘Its not a small word after all’ <https: data-preserve-html-node="true"//www.healthhub.sg/live-healthy/its-not-a-small-world-after-all> accessed 23 November 2024.
3 Tirthani, Said & Rehman “Genetics and Obesity” (2023) National Library of Medicine <https: data-preserve-html-node="true"//www.ncbi.nlm.nih.gov/books/NBK573068/> accessed 26 January 2025.
4 Ibid <<https: data-preserve-html-node="true"//www.ncbi.nlm.nih.gov/books/NBK573068/> accessed 26 January 2025.
5 Adela Hruby & Frank B Hu. “The Epidemiology of Obesity: A Big Picture” (2015) <https: data-preserve-html-node="true"//pubmed.ncbi.nlm.nih.gov/25471927/> accessed 23 November 2024.
6 Tham, Ghani & Cua et al, “Obesity in South and Southeast Asia - A new consensus on care and management” (2022) PubMed Central <https: data-preserve-html-node="true"//onlinelibrary.wiley.com/doi/10.1111/obr.13520> accessed 26 January 2025.
7 E Siong Tee & Siok Hui Voon, “Combating Obesity in Southeast Asia Countries: Current status and the way forward” (2024) Global Health Journal 8, 147-151.
8 Ministry of Health. ‘Annual prevalence of obesity for children aged below 18 over past firve years’ < https://www.moh.gov.sg/newsroom/annual-prevalence-of-obesity-for-children-aged-below-18-over-past-five-years-their-profile-and-assessed-effectiveness-of-preventive-measures> accessed 23 November 2024.
9 Ministry of Health, ‘National Population Health Survey 2022’ <https: data-preserve-html-node="true"//isomer-user-content.by.gov.sg/3/28c3b8f9-9216-46be-8fc9-b614098666a9/nphs-2022-survey-report_final.pdf> accessed 26 January 2025.
10 Chay, Vinh, Ecosse, Kwang & Finkelstein, “Economic burden of excess weight among older adults in Singapore: a cross-sectional study” (2022) BMJ Open <https: data-preserve-html-node="true"//bmjopen.bmj.com/content/12/9/e064357> accessed 23 November 2024.
11 Ministry of Health, ‘National Population Health Survey 2020’ <https: data-preserve-html-node="true"//isomer-user-content.by.gov.sg/3/4bf349c8-25d6-4eb8-bf02-af769321458f/nphs-2020-survey-report.pdf> accessed 23 November 2024.
12 Zhang, Abdin, Sambasivam & et al. ‘Changes in body mass index and its association with socio-demographic characteristics between 2010 and 2016 in Singapore’ <https: data-preserve-html-node="true"//www.frontiersin.org/journals/public-health/articles/10.3389/fpubh.2024.1374806/full> accessed 23 November 2024.
13 Lam et al. “The impact of obesity: a narrative review” (2023) Singapore Medical Journal 163-171.
14 Chay, Vinh, Ecosse, Kwang & Finkelstein, “Economic burden of excess weight among older adults in Singapore: a cross-sectional study” (2022) BMJ Open <https: data-preserve-html-node="true"//bmjopen.bmj.com/content/12/9/e064357> accessed 23 November 2024.
15 Kwang, Lim & Baur, “The global agenda on obesity: what does this mean for Singapore?” (2023) Singapore Medical Journal 182-187.
16 Health Promotion Board, ‘Measures for Nutri-Grade Beverages’ <https: data-preserve-html-node="true"//www.hpb.gov.sg/healthy-living/food-beverage/nutri-grade> accessed 23 November 2024.
17 Health Promotion Board, ‘Healthier Choice Symbol’ <https: data-preserve-html-node="true"//www.hpb.gov.sg/food-beverage/healthier-choice-symbol> accessed 23 November 2024.
18 Health Promotion Board, National Nutrition Survey 2018/2019.
19 Marteau, Fletcher, Hollands & Munafo, Changing Behavior by Changing Environments Cambridge University Press (2020) 193-207.
20 Yang, Zhang & Hu, “Why are we consuming so much sugar despite knowing too much can harm us?” PubMed <https: data-preserve-html-node="true"//pmc.ncbi.nlm.nih.gov/articles/PMC4482352/> accessed 18 February 2025.
21 World Health Organisation, “Guideline: Sugar Intake for Adults and Children.”
22 National Health Service, “Sugars: The Facts” (2023) <https: data-preserve-html-node="true"//www.nhs.uk/live-well/eat-well/food-types/how-does-sugar-in-our-diet-affect-our-health/#:~:text=The%20reference%20intake%20for%20total,more%20information%2C%20see%20Food%20labels.> accessed 18 Feburary 2025.
23 GovTech Singapore, “Gamifying the way to active lifestyles with Healthy 365” <https: data-preserve-html-node="true"//www.tech.gov.sg/products-and-services/for-citizens/health/healthy 365/#:~:text=Healthy%20365%20is%20an%20app,and%20exciting%20one%20through%20gamification>.
24 Yao et al. “Evaluation of a Population-Wide Mobile Health Activity Program in 696 907 Adults in Singapore” (2022) Journal of the American Heart Association <https: data-preserve-html-node="true"//pmc.ncbi.nlm.nih.gov/articles/PMC9238668/> accessed 23 November 2024.
25 Ibid <https: data-preserve-html-node="true"//pmc.ncbi.nlm.nih.gov/articles/PMC9238668/> accessed 23 November 2024.
26 Health Promotion Board, “Healthy Meals in Schools Programme” <https: data-preserve-html-node="true"//www.hpb.gov.sg/schools/school-programmes/healthy-meals-in-schools-programme#:~:text=This%20programme%20aims%20to%20help,habits%20right%20from%20their%20youth.&text=These%20meals%20incorporate%20food%20from,necessary%20for%20their%20growing%20needs.> accessed 23 November 2024.
27 Chan MJ, Tay GWN, Kembhavi G, et al. “Understanding children’s perspectives of the influences on their dietary behaviours” (2022) Public Health Nutrition <https: data-preserve-html-node="true"//www.cambridge.org/core/journals/public-health-nutrition/article/understanding-childrens-perspectives-of-the-influences-on-their-dietary-behaviours/E80B63637BC8E2B06712D10E787A6ACB> accessed 23 November 2024.
28 Bronwlee, Low, Duriraju and et al. “Evaluation of the Proximity of Singaporean Children Dietary Habits to Food-Based Dietary Guidelines” <https: data-preserve-html-node="true"//pubmed.ncbi.nlm.nih.gov/31683840/> accessed 23 November 2024.
29 DHSC Media Team, “Government plans to tackle obesity in England” (2023) <https: data-preserve-html-node="true"//healthmedia.blog.gov.uk/2023/06/07/government-plans-to-tackle-obesity-in-england/> accessed 23 November 2024.
30 Rojas & Rahman, “The Effect of Singapore’s Sugar-Sweetened-Beverage Advertising Ban on Product Entry”(2024) <https: data-preserve-html-node="true"//papers.ssrn.com/sol3/papers.cfm?abstract_id=4887842> accessed 23 November 2024.
31 Diaz, Rezende, Sabag & et al, “Artificially Sweetened Beverages and Health Outcomes: An Umbrella Review” (2023) PubMed Central <https: data-preserve-html-node="true"//pmc.ncbi.nlm.nih.gov/articles/PMC10334147/> accessed 18 February 2025.
32 National Health Service, “The truth about Sweeteners” (2023) <https: data-preserve-html-node="true"//www.nhs.uk/live-well/eat-well/food-types/are-sweeteners-safe/> accessed 18 February 2025.
33 Ministry of Health, Labour and Welfare <https: data-preserve-html-node="true"//www.mhlw.go.jp/stf/seisakunitsuite/bunya/0000161103.html> accessed 23 November 2024.
34 Nakao, Miyamoto, Ueshima & et al. “Effectiveness of nationwide screening and lifestyle intervention for abdominal obesity and cardiometabolic risks in Japan: The metabolic syndrome and comprehensive lifestyle intervention study on nationwide databases in Japan” <https: data-preserve-html-node="true"//pmc.ncbi.nlm.nih.gov/articles/PMC5760033/> accessed 23 November 2024.
35 National Health and Nutrition Survey 2016 (Japan) <https: data-preserve-html-node="true"//www.nibiohn.go.jp/eiken/kenkounippon21/download_files/other/document_en_02.pdf> accessed 23 November 2024.
36 Davina Tham, “Obesity among children on the rise in Singapore, but fat-shaming is not the answer” Channel News Asia (Singapore, 14 January 2023.)
37 The White Paper on Healthier SG 2022 <https: data-preserve-html-node="true"//go.gov.sg/healthiersg-whitepaper-pdf> accessed 23 November 2024.
38 Tham, Lim & Baur “The global agenda on obesity: what does this mean for Singapore?” (2023) Singapore Medical Journal <https: data-preserve-html-node="true"//journals.lww.com/smj/fulltext/2023/03000/the_global_agenda_on_obesity__what_does_this_mean.5.aspx> accessed 23 November 2024.
39 Ministry of Education, Culture, Sports, Science and Technology - Japan (2020) <https: data-preserve-html-node="true"//www.mext.go.jp/content/20230125-mxt-kenshoku-100012603-1.pdf> accessed 23 November 2024.
40 Asakura & Sasaki, “School lunches in Japan: their contribution to the healthier nutrient intake among elementary-school and junior high school children” (2017) <https: data-preserve-html-node="true"//pmc.ncbi.nlm.nih.gov/articles/PMC10261553/#:~:text=Conclusions,and%20minerals%20in%20Japanese%20children.> accessed 23 November 2024.
41 Chaudhary, Sudzina & Mikkelsen “A Review of the Evidence of the Impact of School-Based Interventions” (2020) Pub Med <https: data-preserve-html-node="true"//pmc.ncbi.nlm.nih.gov/articles/PMC7551272/> accessed 26 January 2025.
42 Health Sciences Authority, ‘New Drug Approvals March 2023’ <https: data-preserve-html-node="true"//www.hsa.gov.sg/announcements/new-drug-approval/new-drug-approvals---march-2023> accessed 26 January 2025.
43 Lee , Lim, Asokkumar & Chua, “Current treatment landscape for obesity in Singapore” (2023) Singapore Medical Journal <https: data-preserve-html-node="true"//pmc.ncbi.nlm.nih.gov/articles/PMC10071854/#:~:text=Weight%20loss%20medications%20currently%20approved,durable%20therapeutic%20option%20for%20obesity.> accessed 23 November 2024.
44 Semaglutide-based drugs such as Ozempic and Wegovy can reach a weight-loss plateau, beyond which further weight loss slows or stops. Ryan, D.H, Lingvay et al ‘Long-term weight loss effects of semaglutide in obesity without diabetes’ (2024) Nat Med 30, 2049-2057.