Obesity rates in Singapore is steadily on the rise.

With the pandemic and recent festive season, many of us would have experienced weight gain and worsening of health condition.

A survey conducted in 2022 says 39% of the Singaporeans have gained weight since the COVID-19 pandemic and the significant weight gain was reported among those between 18-30 years of age. A similar pattern has also been observed among the children.

Weight gain can lead to numerous health condition such as high blood pressure (hypertension), diabetes mellitus (Type 2 diabetes), fatty liver, coronary heart disease, osteoarthritis, obstructive sleep apnea (OSA) and more.

Additionally, obesity can limit our productivity and decrease the quality of life. Many of us would have tried different ways to lose the excess weight. However, not all are successful in achieving their goal.

More than ever, to combat the rising obesity rates, there are now newer minimally invasive, patient friendly, reversible, and effective endoscopic treatment options available.

In this Q&A forum, Clinical Assistant Professor Ravishankar Asokkumar, Consultant with the Department of Gastroenterology ＆ Hepatology at Singapore General Hospital (SGH), a member of the SingHealth group, answers your questions on treatment options for obesity.

This 'Ask the Specialist' forum has closed. Thank you for your interest and participation.

1. Posted by l*******
Hi Doctor, 
1. Is the operation covered under MediShield Life?
2. How much will it cost to undergo ESG?
3. Do I need to get a referral from Polyclinic first?

Answered by Clinical ​Assistant Ravishankar Asokkumar : 

Yes, the obesity operations are covered by Medisave. The deductions are determined by class status and the type of procedure. All patients will receive a detailed financial counselling before the procedure to aid them with financial planning.

As stated above, the cost of the procedure is determined by the class status and other factors. It is advisable to receive a detailed counselling by our finance team to determine the accurate procedure cost based on assessment to avoid confusions.

You can call SGH Hotline (6321 4377) to fix an appointment to see us in SGH M clinic or in Obesity Center at SingHealth Tower. Alternatively, you can get a referral from Polyclinic too to consult us.


2. Posted by a******
Hi Dr, may I know:
1.When is weight loss surgery considered necessary? Can I choose it as a first option or must I meet certain criteria to qualify (such as having exceed a certain BMI, or prove that I am unable to comply with diet and lifestyle changes etc)?
2.How effective is weight loss surgery and is the weight loss usually permanent? 
3.Roughly how much (approx. percentage) will my appetite and food intake reduce after the procedure?

Answered by Clinical ​Assistant Ravishankar Asokkumar :

1. Weight loss is an arduous journey and most patients would need help at some point, as it is not always possible to lose the excess weight by diet alone. For Endoscopic Sleeve Gastroplasty (ESG), which is a non-surgical weight loss procedure, the indications are: 

◦BMI >27.5 Kg/m2 with or without obesity related medical conditions 
◦Patients not suitable or not-willing for bariatric surgery 

For patients looking for Bariatric Surgery, which is an invasive and irreversible weight loss procedure, the indications are: 
◦BMI >37.5 Kg/m2 
◦BMI >32.5 Kg/m2 with one or more obesity related medical condition. 

The obesity related medical condition include diabetes mellitus, pre-diabetes, hypertension, coronary artery disease, hyperlipidemia, obstructive sleep apnea, fatty liver, osteoarthritis, and polycystic ovarian disease.

2. Both the ESG and bariatric surgery are effective in inducing weight loss and improving the obesity related medical conditions. The durability of the weight loss results is determined by the patients’ compliance to the diet and lifestyle change long term after the procedure.

3. The endoscopic ESG procedure aims to reduce the size of the stomach by approximately 75-80%. With a significant reduction in the stomach volume, the appetite and meal intake is significantly suppressed. Most patients report a 50% reduction in the meal portion size immediately after the ESG procedure.


3. Posted by s****
When is a person considered unsuitable for bariatric surgery?
How is the recovery like for a person that undergoes bariatric surgery or ESG? Example, is the recovery faster for ESG? What needs to be observed when recovering from surgery, e.g. to only eat soft foods for the first days after surgery? 
What is the level of risk for bariatric surgery and ESG?

Answered by Clinical ​Assistant Ravishankar Asokkumar :

A patient is considered unsuitable for surgery when the risk of surgery is higher than the benefits observed with the procedure. This is determined by several factors and patient-related conditions. Generally, bariatric surgery is recommended for patients with obesity with higher class BMI and those with obesity related medical conditions as described in the previous questions. For patients with obesity in the lower class BMI group, bariatric surgery is less preferred.

The recovery from ESG is faster than bariatric surgery. The patients stay in hospital less than 24 hours. They can resume their daily activity by next day and become completely symptom free by 3 days. The procedure related discomfort last only during the first 24 hours. The chance of having persistent vomiting or reflux or nutritional deficiencies after ESG is extremely low. During hospitalisation after ESG, the patient will be reviewed by the doctor and dietician and a specialised diet plan will be provided to the patient. The escalation of diet happens in phases with liquid and pureed diet in the initial phase to solid diet in the later phase. The patient preference will be taken into consideration while designing the meal plan.

The risk of ESG is very low (<2%) compared to bariatric surgery. ESG is a minimally invasive, reversible endoscopic procedure that preserves the anatomy, blood supply and nerve supply of the stomach. The procedure does not involve any resection of the stomach. Thus, the serious adverse event rates are extremely low and infrequent compared with surgery.

 

To learn more about weight loss procedures, read these articles:

Bariatric Surgery: Different Types, Pros and Cons

Endoscopic Sleeve Gastroplasty (ESG): Treating Obesity without Surgery

 

About Clin Asst Prof Ravishankar Asokkumar

Clinical Assistant Professor Ravishankar Asokkumar is a Consultant gastroenterologist and advanced therapeutic endoscopist at the Singapore General Hospital (SGH), and Clinical Assistant Professor at the Duke-NUS Medical School, Singapore. He is experienced in managing common and complex gastrointestinal disorders including obesity, colonic polyps resection, colon cancer screening, early gastric and esophageal cancer resection, gastrointestinal bleeding, gastroesophageal reflux disease, irritable bowel syndrome, dyspepsia, liver disease, viral hepatitis and inflammatory bowel disease.

He established the first ever bariatric endoscopic program for weight loss in Singapore at the Obesity Centre, SGH. Under this program, he performs the minimally invasive endoscopic sleeve gastroplasty procedure, primary obesity surgery endoluminal procedure, gastric balloons, post gastric bypass stoma reduction and post gastric sleeve resuturing procedure for weight reduction. He is the first Gastroenterologist in Singapore to be recognised as the National fellow by World Obesity Federation.

Dr. Ravishankar has also published extensively in peer-reviewed, high impact factor medical journals and authored several book chapters. He has collaborated internationally, and is a regular invited faculty in medical conferences both locally and internationally. He is a faculty in the Gastroenterology, Senior Residency training program and is a trainer for advanced endoscopic procedures for fellows.

Ref: I23