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Addressed To:
Permanent Secretary, Ministry of Education
POLICY MEMO ON COMBATING CHILDHOOD OBESITY
Jointly Written by:
Benjamin Ng Dr Lyn JAMES, PBS
Director, Manpower Policy and Planning Division, MINDEF Director, Public Health Group
Epidemiology and Disease Control Division, MOH

THE ISSUE OF CHILDHOOD OBESITY
It was reported that despite isolated areas of improvement, no country to date has reversed its obesity epidemic PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Sb2JlcnRvPC9BdXRob3I+PFllYXI+MjAxNTwvWWVhcj48
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ADDIN EN.CITE.DATA (1). In Singapore, the breakthrough will require a Whole-of-Government and multi-stakeholder efforts, and there is an urgent need for action in combating the anticipated obesity epidemic. Downstream, the rising prevalence of obesity has over the years also impacted the SAF and more resources and efforts have to be invested in improving their physique before they proceed to their military vocational training. Notwithstanding this, the public health concern of chronic diseases as a resultant effect would be the huge socioeconomic burden on this nation.
BACKGROUND
While there was a drop in adult overweight rates (from 40.1% in 2010 to 36.2% in 2017), 13% of children in mainstream schools were overweight in 2017, up from 11% in 2011 ADDIN EN.CITE <EndNote><Cite><Author>Ministry of Health Singapore</Author><Year>2018</Year><RecNum>34</RecNum><DisplayText>(2)</DisplayText><record><rec-number>34</rec-number><foreign-keys><key app=”EN” db-id=”5xrxxpzz4at00pef9aa5xf0pdxpp920fwzat” timestamp=”1535703336″>34</key></foreign-keys><ref-type name=”Web Page”>12</ref-type><contributors><authors><author>Ministry of Health Singapore,</author></authors></contributors><titles><title>Speech by Dr Amy Khor, Senior Minister of State for Health</title></titles><volume>2018</volume><number>Aug 28, 2018</number><dates><year>2018</year></dates><urls><related-urls><url>https://www.moh.gov.sg/content/moh_web/home/pressRoom/speeches_d/2018/speech-by-dr-amy-khor–senior-minister-of-state-for-health-at-th.html</url></related-urls></urls></record></Cite></EndNote>(2). This trend is worrying as it not only increases the risk of chronic diseases like Diabetes, Hypertension, and Heart Diseases downstream, the burden of these diseases will also adversely affect the socioeconomic fabric of the nation. Daniels (2006) states that health professionals have discovered that some disease processes, such as hardening of the arteries, once thought to be predominantly adult health concerns can in fact begin in childhood. In addition, the risk of elevated blood pressure ranges from 2.5 to 3.7 times higher for overweight children PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EYW5pZWxzPC9BdXRob3I+PFllYXI+MjAwNjwvWWVhcj48
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ADDIN EN.CITE.DATA (3). Generally, food consumption and expenditure of energy are major factors influencing weight gain. Whilst MOE has, as part of the schools’ Physical Education curriculum some influence on the latter, the influence on food consumption is less evident as it is not part of academia. MOE has however supported health promotion by embracing initiatives from Health Promotion Board (HPB) with favourable results:
Health Promoting Framework. The framework provides structure approach to support schools in building a supportive health promoting culture and environment. Uptake has increased 61% in 15/16 compared to 24% from 14/15 ADDIN EN.CITE ;EndNote;;Cite;;Author;Health Promotion Board;/Author;;Year;2018;/Year;;RecNum;35;/RecNum;;DisplayText;(4);/DisplayText;;record;;rec-number;35;/rec-number;;foreign-keys;;key app=”EN” db-id=”5xrxxpzz4at00pef9aa5xf0pdxpp920fwzat” timestamp=”1535704258″;35;/key;;/foreign-keys;;ref-type name=”Web Page”;12;/ref-type;;contributors;;authors;;author;Health Promotion Board,;/author;;/authors;;/contributors;;titles;;title;Health Promotion Board Annual Report 2016/2017;/title;;/titles;;volume;2018;/volume;;number;Aug 28, 2018;/number;;dates;;year;2018;/year;;/dates;;urls;;related-urls;;url;https://www.hpb.gov.sg/docs/default-source/annual-reports/hpb-annual-report-2017.pdf?sfvrsn=88d9f372_2;/url;;/related-urls;;/urls;;/record;;/Cite;;/EndNote;(4).

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ADDIN EN.CITE.DATA (4, 5).
Unfortunately, evident from latest figures in the aforesaid, the trend of child obesity is on a worrying rise, and more could be done before child obesity reaches epidemic proportions.

RECOMMENDATIONS
Single Operator for School Dining Facility. Instead of getting HPB to improve or be more aggressive in their programmes, MINDEF/SAF and MOH are recommending that MOE change their longstanding policy of extending canteen stalls to individual operators, and instead, outsource it to food industry players to propose operating school dining facilities and have tailored menus based on prescribed nutritional values. This forms a crucial part of the strategy to combat the rising obesity rates in school-going children, especially in their formative years spanning primary and secondary school education of at least 10 years and consuming at least 1 meal in school almost daily.
Collaborative Policy Effort. This policy seeks to complement existing health promoting programmes targeting healthy dietary habits and consumption. It is anticipated that the resultant effects of decreased obesity rates will improve population health as these children transit into adulthood, and a downstream benefit for SAF as the cohort of eligible males fulfil their national service fulltime (NSF). MINDEF/SAF and MOH as part of the multi-stakeholders in this fight endeavour to be part of this effort in combating childhood obesity, and will be amenable in discussing the provision of assistance toward this policy change.

SCHOOLS BEST POSITIONED TO COMBAT CHILDHOOD OBESITY
Schools have the doubled-edged position of being both a key cause of and solution to childhood obesity. McDermott (2012) cites arguments that schools contribute to the childhood obesity crisis by offering poor-quality meals, selling ‘competitive foods’ and beverages in western countries PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Qb3dlbGw8L0F1dGhvcj48WWVhcj4yMDE1PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (1). Unlike many countries, MOE schools do not have a single operator system, relying instead on individual-run stalls. The lack of a precedence in our context allows for ease of implementation in regulating the nutritional criteria of food in schools. There will also be equity in the receipt of nutrition in schools regardless of socioeconomic status, as the lowered pricing can be premised on the principles of economy of scale, coupled with the recommendation of a nominal rental fee for the dining facility infrastructure.

FACTORS AND EVIDENCE INFLUENCING CHILDHOOD OBESITY
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ADDIN EN.CITE.DATA (7). Children should not be penalised with premiums placed on unhealthy options considering their meagre pocket money. However, these taxation and premiums placed on sugary drink are marginal and could well be afforded by children in a more affluent Singapore today. Roberto et al (2015) suggests that the environment clearly interacts with personal vulnerabilities in problematic ways that promote overconsumption of unhealthy foods. Thus, it is more productive to address the obesity epidemic by acknowledging that environmental effects that exploit individuals’ vulnerabilities can make it difficult for people to make healthier decisions PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Sb2JlcnRvPC9BdXRob3I+PFllYXI+MjAxNTwvWWVhcj48
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ADDIN EN.CITE.DATA (1). For young children, the decision to make healthy choices becomes even more challenging as there may be limited understanding of what healthier choices entail. In fact, actors from the food industry are targeting children in its campaign to promote energy-dense and nutrient poor food via social media, leaving impressionable children making choices based on attractive advertising ADDIN EN.CITE ;EndNote;;Cite;;Author;Tan;/Author;;Year;2018;/Year;;RecNum;13;/RecNum;;DisplayText;(10);/DisplayText;;record;;rec-number;13;/rec-number;;foreign-keys;;key app=”EN” db-id=”5xrxxpzz4at00pef9aa5xf0pdxpp920fwzat” timestamp=”1535269952″;13;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;Tan, LeeAnn;/author;;author;Ng, See Hoe;/author;;author;Omar, Azahadi;/author;;author;Karupaiah, Tilakavati;/author;;/authors;;/contributors;;titles;;title;What;apos;s on YouTube? A Case Study on Food and Beverage Advertising in Videos Targeted at Children on Social Media;/title;;secondary-title;Childhood Obesity;/secondary-title;;/titles;;periodical;;full-title;Childhood Obesity;/full-title;;/periodical;;pages;28-290;/pages;;volume;14;/volume;;number;5;/number;;dates;;year;2018;/year;;/dates;;pub-location;United States;/pub-location;;publisher;Mary Ann Liebert, Inc;/publisher;;isbn;2153-2168;/isbn;;urls;;related-urls;;url;http://nus.summon.serialssolutions.com/2.0.0/link/0/eLvHCXMwnV05T8MwFLagSIiB-yqXPMFCSxInjj2htmqFBF2gMHQJvgJdHETagX-PX5IWtR0QbJHiOIn9_A6_731GiARNr7GgE0woSRpRLblgikoWEA3EaoJJZWK_SKa328HTkHTvyXAeZOlcMYAYl8QRhe6GxS5kXiHk-I16HwFGC0CRJF5Fa4FHCNDoP_YfZtstUILqF4APZ-NII_Apqxg3l3qYs1CbUEAmrK2-YsH5LIxQbxu9_uy8FOgTv2knJQ1i_rZM7_iPv9pBW5WDilulRO2iFWP30Hq_SsHvowzIvq9ynFnsNMVgIs0tbuGOM4YYMIlfcKOXZRoLq3HbuJXiNBaenvvsDCUeWfwy0ibL8aCAoRvXdow7VVU5PF_WDGN4qThAz73uoHPXqE5taChwBsFdJ2lKpVBhyj3BaagkibSLtFlqjHEhsYyoiJUW1LhYSRodG649LWMqfEUVOUQ1m1lzjLBzVryUca2M1iHzJGMhE06QeBqRiCpWR5fTmUo-SnKOpEiqM5644Utg-ID8NK6j6_l5_K35UTnLs2bOaLOIhvzkbx2dog24LuG9Z6g2_pyYc7TqhOOiEM9vbPjsgA;/url;;/related-urls;;/urls;;electronic-resource-num;10.1089/chi.2018.0037;/electronic-resource-num;;/record;;/Cite;;/EndNote;(10). It was also noted that in a high-incomed country like Singapore, the high ratio of the female workforce will undoubtedly give rise to demands for convenient food options, including processed food. Factors like scarcity of time and the convenience of eating out rather than disposable income were the predominant factors in the eating-out culture, with children and youth favouring fast food restaurants ADDIN EN.CITE ;EndNote;;Cite;;Author;Naidoo;/Author;;Year;2017;/Year;;RecNum;33;/RecNum;;DisplayText;(11);/DisplayText;;record;;rec-number;33;/rec-number;;foreign-keys;;key app=”EN” db-id=”5xrxxpzz4at00pef9aa5xf0pdxpp920fwzat” timestamp=”1535437958″;33;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;Naidoo, Nasheen;/author;;author;van Dam, Rob M.;/author;;author;Ng, Sheryl;/author;;author;Tan, Chuen Seng;/author;;author;Chen, Shiqi;/author;;author;Lim, Jia Yi;/author;;author;Chan, Mei Fen;/author;;author;Chew, Ling;/author;;author;Rebello, Salome A.;/author;;/authors;;/contributors;;titles;;title;Determinants of eating at local and western fast-food venues in an urban Asian population: a mixed methods approach;/title;;secondary-title;International Journal of Behavioral Nutrition and Physical Activity;/secondary-title;;/titles;;periodical;;full-title;International Journal of Behavioral Nutrition and Physical Activity;/full-title;;/periodical;;pages;69;/pages;;volume;14;/volume;;number;1;/number;;dates;;year;2017;/year;;pub-dates;;date;2017/05/25;/date;;/pub-dates;;/dates;;isbn;1479-5868;/isbn;;urls;;related-urls;;url;https://doi.org/10.1186/s12966-017-0515-x;/url;;/related-urls;;/urls;;electronic-resource-num;10.1186/s12966-017-0515-x;/electronic-resource-num;;/record;;/Cite;;/EndNote;(11). This policy reinforces the benefits of reduced unhealthy food exposure, with at least one healthy meal consumed in school almost daily.

The core intervention of this policy change hinges on replacing canteen food with tailored nutrition to meet the needs of school children. Other factors that will play crucial roles in its successful implementation includes social media and communications efforts, and community stakeholders, e.g. parents, caregivers, and teachers. Failure to introduce these recommended efforts as a collective policy in improving healthy eating behaviours may run the risk of rendering siloed efforts ineffective. For example, if the vending machines were to remain, the children would still have the option of getting their sugar sweetened beverages within the school premises, during school hours. The efforts in inculcating and reinforcing the health behaviour would be undone.

WAY FORWARD
To implement this concrete policy option that compels healthy eating in schools, the buy-in of parents and caregivers are crucial. They will potentially be the biggest proponents of this policy move, since the message of “healthy eating for healthy growth” for their child will resonate strongly. The integration of nutrition education during the formative years of life will inculcate and establish dietary habits. The other important aspect would be collaborative participation of these children in deciding the menu, as they will ultimately be the consumers of this food programme. At the collaborative level, children are not only involved as experts but also take part at various degrees in initiation, planning, and analysis PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MYXJzc29uPC9BdXRob3I+PFllYXI+MjAxODwvWWVhcj48
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ADDIN EN.CITE.DATA (1).
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