Commentary: Singapore children are getting fatter and it’s worrying especially during a pandemic

SINGAPORE: As a paediatrician assessing children with acute COVID-19 infection for their suitability for home recovery during this pandemic, it struck me that a worrying proportion appeared overweight.

As part of any paediatric assessment, we routinely ask for their weight as dosage of medications is often based on weight.

By my estimate, about one in five kids I saw was overweight (body mass index over 85th percentile) or worse, obese (above 95th percentile). One child in primary school was even morbidly obese, that is, the Body Mass Index (BMI) was higher than 99 per cent of children of the same age.

What I am seeing in my clinic is reflective of national data and it worries me. About 13 per cent of Singapore schoolchildren were obese in 2017, up from 11 per cent in 2013, according to the Ministry of Health (MOH)’s National Population Health Survey when data on childhood obesity was last captured.

The pandemic has made things worse. KK Women’s and Children’s Hospital reported seeing more cases of overweight children since COVID-19 hit.

This might be due to a more sedentary lifestyle amid restrictions. Schoolchildren couldn’t mingle with friends in other classes during recess, participate in group activities like PE and co-curricular activities or when they were stuck at home for home-based learning.

OBESITY INCREASES RISK OF SEVERE COVID-19 AND OTHER DISEASES

In our current situation this is worrying, as obesity may increase the risk of severe COVID-19, including in children. Stanford University researchers recently found the virus targets fat cells – making those who are overweight at greater risk of serious illness.

The exact mechanisms for this association need further study but the signs are there – being overweight is a risk factor.

A common misconception people have is to think of obese children as just being fat. The reality is it affects our body systems: Obesity contributes to hormonal imbalance and increases resistance to insulin in Type 2 diabetes. The more obese one is, the higher one's insulin resistance.

Excess weight puts more load on our joints and can lead to osteoarthritis. Obesity is also one of the biggest contributing factors to plaque formation in our heart vessels – which can start from adolescence or even earlier – and present later in adulthood as coronary heart disease.

Studies also show about 70 per cent of obese kids grow up to be obese adults. If we tackle obesity at childhood, we can reap many beneficial downstream outcomes. Adults I know who shed extra pounds find their lives improve – they sleep better, their pre-diabetes and fatty liver conditions resolve, they no longer need medications, monitoring devices or even frequent visits to their doctors.

In the long run, it reduces healthcare costs too. A study done in the US estimated that the direct medical cost of child with obesity is between US$12,660 and US$19,630 higher than a child of normal weight and allowing for normal weight gain to adulthood.

CHILDHOOD OBESITY NOT A NEW FIGHT

Many obese children I see also have overweight or obese siblings and parents. Quite often, they come from middle to lower income families, with both parents working to supplement the family income. They tell me it’s hard to cook healthy food and “quick and easy” fast food meals are the norm. 

Those who work long hours also don’t have the time nor energy for activities so everyone leads a sedentary lifestyle at home. Of course, there are also genetic factors – not everyone with unhealthy lifestyles is overweight.

But there is no denying our lifestyles have an impact on our weight – largely being sedentary, big portions when eating, snacking, overconsumption of hidden high calories like sugared drinks, late dinners and binge eating after attempting dieting are common.

So how do we address these?

Those growing up in the 90s would be familiar with the now-defunct Trim-and-Fit (TAF) club in schools that compelled overweight children to skip recess to exercise – sometimes in horror of having to do so in front of peers. While some success was reported, a study also suggested it may have contributed to eating disorders.

Since 2008, schools refer to a Holistic Health Framework for all students, not only those who are overweight.

At the tertiary healthcare level, both paediatric hospitals (NUH and KKH) run clinics that focus on childhood weight management. It is a multi-disciplinary approach involving a paediatrician, oftentimes a paediatric endocrinologist, dietician and occupational and physical therapists and sometimes a medical social worker.

Successful weight management often requires consistent lifestyle changes and we know this is hard to achieve. There are multiple and diverse challenges and weight management clinics identify what the most likely barriers are for specific cases and develop targeted interventions.

Examples of these barriers include poor education of what normal, healthy weight is, risks of obesity, poor motivation, concurrent mental health problems and lack of family support.

Hopefully, these interventions work and we won’t need to reach the stage of military-style weight loss boot camps, like in China, where childhood obesity has also become a rising public health concern. In Singapore, only overweight boys must serve a longer stint for National Service.

We want to prevent obesity and these health issues before they even happen. It is easier to enforce healthy lifestyle changes as a child and these changes can become good habits that children can continue to practice as adults and later, pass down to their own kids when they become parents themselves.

WHAT WE NEED TO DO MORE OF

Initial strategies should aim for a slower weight gain first followed by targeting to reach a healthy weight as the child grows.

From my experience, a significant proportion of overweight children appear to be from families with a family or parental history of obesity, from lower socio-economic strata or lower educational backgrounds. If this can be confirmed, we can then focus our energies there.

Intervention for such kids is already in place. They range from school to community interventions and tertiary healthcare facilities. School interventions are free and those by the Health Promotion Board (HPB) interventions are affordable.

If finances are a barrier, a medical social worker can help many low-income families. The most common and challenging barrier to break through is motivation.  A laissez-faire attitude towards the child’s health, poor commitment in sticking to the treatment plan, poor attendance at intervention sessions are all too common. 

For intervention to succeed, the whole family needs to rally together. However, every other member of the family may have different competing priorities making family-based treatments even more challenging.

A collaboration, perhaps between MOH-HPB, ECDA and MOE – culminating in a multi-ministry effort will probably be most fiscally responsible, efficient and effective.

Some gaps that can be addressed include: Increasing community-based initiatives after office-hour programmes and developing programmes that nurture a child’s natural predilection for play thereby embedding exercise into their routine. It is imperative we do not stigmatise the overweight child as this will likely lead to negative self-image and potentially leads to future eating disorders.

The 2020 iteration of MOH’s survey indicates that obesity rate among adults has risen to the highest level since 2010, with 10.5 per cent of Singapore residents found to be obese. Our nation has declared a war on diabetes and adult-onset diabetes is associated with obesity.

Let’s address this problem of childhood obesity as a priority. It is far better to prevent a war than to fight one.

Dr Lim Yang Chern is consultant paediatrician at the Thomson Paediatric Centre (Jurong East).