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EF: What are the current priorities of the Singapore Association for the Study of Obesity (SASO)? 

KT: SASO, Singapore Association for the Study of Obesity, was founded in 2001. Obesity became an evident problem in Singapore as late as 2010; following the world trend, we are a developing country on this topic, and when I took over, it had already gone awry.  

Our mission was since the beginning to promote the research and study of obesity and be a platform to bring stakeholders together. We are a professional medical organization, not just doctors but people from different walks of obesity. As the country matures, we are working to change the social perception of obesity and let it be seen as a disease in its own right. Many organizations worldwide recognize obesity as a major problem; the WHO and Singapore do. In the process of prioritizing obesity, the narrative is important. People tend to see it as a risk factor, like smoking; however, the understanding of science has developed, especially over the last two decades. Obesity, like diabetes, starts from things that have gone wrong in the body, from an imbalance. The mindset of concept change has been very slow to take on, especially in Asia. While we are doing the right things, changing food and environmental policies, with the government putting in resources, obesity rates are still rising. What are we doing wrong? The scientific-based body has put a lot of effort into promoting information on obesity correctly, treating obesity as a disease. It is not about going on a weight loss diet for three months; there must be a follow-up, keep making the changes, and disease management. It is not because people are lazy or lack willpower, as some doctors might conclude, but unfortunately, this leads to general stigma and bias and not addressing or treating the problems of obesity correctly. We serve as a platform with information, expertise, and resources. One of our aims is to link people up; we are a community of healthcare professionals who believe in advancing knowledge and education about obesity and advocate for people living with obesity. One of the biggest misunderstandings is that obese and overweight people are lazy; they internalize this bias and believe they are not good enough. They don't go to a doctor and think they are fat because they don't try hard enough. They don't come in for health screening, don't take up healthy behaviors, suffer the inequality of healthcare delivery, and are psychologically and physically affected. Our role is to fill in the gaps through scientifically based knowledge and education. 

EF: Could you elaborate on the overweight and obesity prevalence in Singapore? Numbers are rising worldwide, but how does this translate into Singapore? 

KT: Overweight rates are high in Singapore, 10,8% right now, meaning one in nine or ten people are obese, but at least the rate has held steady, and the WHO aims to halt obesity rates. Between 2004 and 2010, Singapore nearly doubled its obesity rates, rising 60%, when the government woke up and became more involved. We are not trying to reverse the trend because it is predicted that if we can stop it, we can avert the downstream effect of many NCDs. There is a WHO report about reducing NCD deaths by 30% by 2030, and they recognize that if we don't deal with obesity, it won't be possible. We have a National Population Health Study every six years or so; the last was in 2017, and the previous was in 2010. Since 2017 our rates have risen a little, from 8.7 to 10.8%. We have held it steady in the big scheme of things. When referring to obesity rates, we use a universal weight measure for comparison with the rest of the world, the BMI, with a body mass index of 30. Whether a person is Caucasian, Asian, Afro-American, or whatever, everybody uses a body mass index of 30. But Asians cannot tolerate a lot of fat, and the same BMI means a lot more fat for an Asian, which tends to be in the wrong areas, mainly in the visceral or central location -the belly area- causing heart diseases and diabetes. The relevant BMI cut-off nearly doubles for an Asian. We now use lower BMI cut-offs appropriate to Singaporeans and Asians. This reflects in our obesity- reaching 21% of what we call health risk. Regardless we need to look at what is meaningful for our population, and one in five Singaporeans is at weight risk. 

And there are many problems related to obesity and weight risk. Nearly 60% of Singaporeans are in the so-called overweight and obesity range, which is very high, and measures must be taken.  

EF: Do the government and pertinent institutions agree with your lower cut-off perspective? 

KT: Across the board, when reporting obesity rates to the WHO, all countries still use the standard BMI 30 to be easier to compare in the same metric, but each country has its own definitions. Asian countries use a BMI of 25, except China, Singapore, and Malaysia. We are quite lenient in Singapore, it is about body type, and we are predominantly East Asian, so our cut-off can be a bit higher, and we use 27. When it comes to public health clinical action points, our government recognizes health risks and, when giving reimbursements for treatments, uses the lower cut-offs relevant for Asians (Public Health Action Cut Points). Our government acknowledges Singapore has a problem; not recognizing the problem contributes to NCDs which translates to healthcare costs. 

EF: What lessons and synergies can be transferred between the relevant associations?  

KT: Each country is in different phases of developing relevant obesity policies: infrastructure, food environment, physical activity, transport, etc. As a platform, we inform what works; it can be something as simple as a digital app. Singapore is used to digital apps, they have been used for quite some time already, using incentives to match behavior, and this is an area that continues to be refined. Singapore is very small but has a dense population of working adults, so we can share best practices, if not with countries but with cities of similar demographics and learn from each other. Learnings can be taken and adapted. As a platform, we get people to share.  

We have an obesity policy and engagement network called OPEN; a global network easily found online. Europe has a platform where countries have their chapters. We share best practices through this platform and help each other advocate and empower countries that need help. In Italy, the parliament has recognized obesity as a disease; therefore, more funding is available. Recognition allows for financing and access to care for people living with obesity, increased funding for medical education, and empowered primary care physicians in terms of treatment and prevention, which is where we want to arrive. In 2021 we set up a network for Southeast Asia, and due to Covid, it was all done virtually. We met people from the Ministry of Health of different countries, Brunei, Philippines, Vietnam, Cambodia, etc., and getting people to hear what was going on from a world platform was excellent. 

The platform also gives inspiration, as working in silos can be very disheartening, particularly when dealing with obesity. A platform helps; Malaysia has set up its obesity chapter, as has Singapore. Malaysia has submitted a white paper to lobby for a higher prioritization of obesity in the country –Malaysia has a bigger problem than Singapore. A lot is going on. 

EF: Diabetes is directly related to obesity, but are you collaborating with companies or associations in disease areas other than cardiovascular to share expertise for better development?  

KT: The big pharma companies are powerhouses with very strong scientific departments and are indeed developing health. Singapore is a very small market for diabetes and obesity, so we partner with them when they need feasibility trials. Singapore has very well-trained and experienced clinicians for obesity and very good teams of doctors that handle obesity and diabetes. Thanks to the excellent infrastructure in public healthcare, we have been able to develop state-of-the-art centers and clinical practices. We have our local research, not directly with pharmaceuticals, but with real practices and data in a world platform -where we come in sharing expertise. We can share our experience and what we have done with countries that may not have the information and services. Unfortunately, there are not many players in the obesity world, Novartis is one of them, and they have been willing to partner with us neutrally. 

We have run clinical training programs covering different aspects of obesity, such as fatty liver, infertility, and cardiovascular disease, all of which are linked to obesity. We have brought experts to train and deliver education. We have reached out virtually to different people for the training of primary care physicians.  

We also work with our bariatric surgeons and the Bariatric Surgical Society (J&J and Medtronic invest in much of their training). Once a year, our endocrine societies, SASO, and our Obesity & Metabolic Surgery Society hold a scientific conference. It is a neutral platform to present a broad spectrum of obesity issues for educational purposes. Companies participate in funding education and training. We aren't doing cardiovascular research concerning obesity, but things will change as people start to link obesity to other diseases, such as cancer –officially to thirteen types of cancer. We have a way to go before we catch up and reduce obesity rates in Singapore. We are still at the stage where we are trying to create awareness of the issue, study it to then reverse the trend. 

EF: In three years, SASO will celebrate its 25th anniversary; of what achievements are you most proud?  

KT: First and foremost, I am delighted that over the past twenty years, interest has been increasing, including from the clinical aspect, more professionals willing to be trained and develop skills in this area, and we are seeing new specialties coming in. Before, it was mainly endocrinologists; now, we see cardiologists, family physicians, dietitians, and researchers getting involved. I am gratified to see our field has grown to include more people from different worlds to complement each other so we can move further. Everybody is keen to learn from each other and to share, and the platform opens a lot of collaborations. As a small country, our strength lies in unity and building upon what we have done. Our human resources are small, and the patient pool isn't very big, so if we pool our data (experience, outcomes, and economics) together, we can go much further. Our data and guidelines and local expertise can contribute to the region.  

EF: Singapore might be small, but it is a very value-driven market, just like your association. Is there a final message you would like to share?  

KT: At the end of the day, it is about creating value. My hospital team is small, but we dream big, and our dream inspires us to keep moving forward; without it, we would quit and give up, especially in a field such as obesity. The difference we can make to the people who live with obesity is a critical aspect that propels us forward. We want to make a difference. We don't feel superior to the patients or condescend to change their lives; we understand how challenging it is for them to change in an environment and with families that work against them; a bigger push than drugs are needed. We see ourselves as partners who journey with our patients living with obesity. If we can make them a little healthier and more positive, there is value in what we do.  

For our 25th anniversary, I hope we have a platform where people with lived experiences have a voice; in Asia, the patient's voice isn't loud; it is getting louder, but not like in Europe or Australia, where patient bodies are strong. We hope to add value to our society beyond medical professions with public support and education and fundamentally make a difference in people's lives, never losing sight of our initial vision and passion. Covid has shown how disruptive things can be in any walk of life, and we can be caught off guard. We must be true to the reason we embarked on this journey -our vision- and we will get there. Build on what our predecessors have left behind and leave a legacy others can build on. It is not about my work and what I have done, which will only be venerable if others can build on it.  

May 2023