GPs are well placed to manage obesity together with all its attendant chronic medical conditions. Find out how the Singapore General Hospital Obesity Centre can work with you on complex cases to provide the best care possible for patients.
GPs are well placed to manage obesity together with all its attendant chronic medical conditions. Find out how the Singapore General Hospital Obesity Centre can work with you on complex cases to provide the best care possible for your patients.
INTRODUCTION
Obesity, defined as a body mass index (BMI) of ≥ 30 kg/m2, is a chronic disease and serious public health problem leading to mechanical and metabolic complications – such as type 2 diabetes mellitus (T2DM), hypertension, obstructive sleep apnoea (OSA), cerebrovascular accidents, ischaemic heart disease and depression.
The BMI cut-off in Asians is lowered by 2.5 kg/m2 as they develop complications at lower BMI compared to Caucasians.
The global prevalence of overweight and obesity has risen by 27.5%, from 857 million in 1980 to 2.1 billion in 2013.
In Singapore, the rise in rates of T2DM closely tracks the increase in obesity. The 2017 National Population Health Survey reported rates of 8.9% for obesity and 8.7% for T2DM. If rates of obesity and T2DM continue to rise unchecked, the prevalence of diabetes may hit 15% by 2050, giving Singaporeans a lifetime risk of 44% for developing diabetes.
CASE STUDYBackground A 61-year-old Malay woman was seeing her general practitioner (GP) for the management of hypertension, migraines, osteopenia and osteoarthritis (OA) of the knee. Her GP referred her to orthopaedics for OA knees and she was counselled that weight loss would help with her knee pain. Her GP then referred her to the Singapore General Hospital (SGH) Obesity Centre where she initially saw the Endocrinologist and Dietitian. At the Endocrinologist visit, it was noted that her blood pressure (BP) was well controlled and that she was on regular follow-up with her own GP. She was deemed fit for exercise and therefore referred to the Physiotherapist. The Dietitian noted that the patient was following a low-calorie diet, however had been unsuccessful in losing weight. She was advised to try meal replacements and was started on one meal replacement a day for breakfast. The Physiotherapist did a fitness assessment, prescribed the patient an exercise programme and advised her to come once a week for a supervised exercise session at the Lifestyle Improvement and Fitness Enhancement (LIFE) Centre gym on the 4th level at Outram Community Hospital. Patient Outcomes The patient was compliant with all recommendations and came back for follow-up three months later. It was noted that she had reduced her weight by 3 kg. She was happy with her progress, however wanted to lose more weight. She was motivated and keen to embark on a very low-calorie diet (VLCD), which consists of three meal replacements a day to achieve a total daily energy intake of < 800 kcal per day. She was warned about the potential side effects of hunger, dizziness, headaches, cold intolerance and constipation. She felt better after five days on the diet and managed to lose another 5 kg after four weeks of VLCD. Her GP noted that her BP had improved and she was able to stop her BP medication. She also managed to transition from VLCD to a healthy lower-calorie diet and maintain her weight loss. She also continued her exercise on her own and attended the supervised exercise sessions at the LIFE gym once or twice weekly. |
TREATMENT OPTIONS BY GPs
Pharmacotherapy is one of the treatment modalities used by GPs and endocrinologists for managing obesity. Medications can be initiated as adjuvant therapy together with lifestyle modification to kickstart patients’ weight loss, when lifestyle changes have not been effective or sustainable in losing weight.
Pharmacotherapy can be considered for patients who are averse to invasive procedures or surgeries.
WHEN TO REFER FOR SPECIALIST CARE
Patients suffering from obesity (BMI ≥ 27.5 kg/m2) and other associated metabolic conditions can be referred to the SGH Obesity Centre for comprehensive management.
The multidisciplinary team at the SGH Obesity Centre consists of endocrinologists, surgeons, gastroenterologists, dietitians, physiotherapists, psychologists, pharmacists, specialty nurses and clinical coordinators. We use evidence-based integrated approaches to help people with obesity lead a healthier lifestyle and in the process, achieve sustained weight loss, weight maintenance and improved health for themselves.
TREATMENT OPTIONS BY SPECIALISTS
Medical weight loss (Endocrinologists)
As mentioned, pharmacotherapy is one of the treatment modalities used by endocrinologists for managing obesity. There are a few different medication options available in Singapore which can result in a weight loss of between 3-10%.
After obtaining a thorough medical history from the patients, the Endocrinologist will discuss the different pharmacotherapy options with them. Based on their medical history and personal preferences, a mutual decision will be made about the best treatment option for each particular patient.
Medications can also be used postoperatively if patients are struggling with inadequate weight loss and/or weight regain.
Metabolic bariatric surgery* (Bariatric Surgeons)
Surgical intervention should be recommended for a subset of patients who are unable to lose weight through medical and lifestyle interventions.
Surgery is medically indicated if a patient’s BMI is:
- ≥37.5 without comorbidities (Class III obesity), or
- ≥32.5 (Class II obesity) with comorbidities such as
diabetes, hypertension, hyperlipidaemia and OSA.
Weight loss through metabolic bariatric surgery can lead to significant improvement in these metabolic disorders.
Endoscopic bariatric procedures* (Gastroenterologists)
Endoscopic procedures such as insertion of gastric balloons and endoscopic gastroplasty can be considered for patients whose BMI is ≥ 27.5 to ≤ 32.5.
*Patients will be assessed for their suitability for a surgery/procedure by the multidisciplinary team.
ALLIED HEALTH / LIFESTYLE MODIFICATIONS
Dietitians
Dietary management includes individual consultation with a dietitian to better understand the individual’s current dietary habits. Patients are taught to lose weight by quantifying food and energy intake whilst having an individually-tailored balanced diet plan. Realistic goals for weight loss/management are set, together with the identification of barriers to healthy eating and strategies to overcome them.
Physiotherapists
Physiotherapists support the individual’s weight management goals with safe and effective exercise sessions for a healthier lifestyle. A detailed fitness assessment will be conducted by a physiotherapist for an individually-tailored exercise prescription. Physiotherapists can also provide professional supervision during the exercise sessions to ensure
correct technique and safety.
Psychologists
Psychologists help in maximising the success of weight loss by guiding individuals to develop healthier eating behaviours, and manage lifestyle changes and stress that might hinder their weight loss efforts.
They also help patients identify their motivation to change, leading to sustained improvements and improving their quality of life. Psychologists are crucial in supporting patients who find it extremely difficult to adjust and cope with lifestyle changes that are needed for their weight loss.
Pharmacists
Pharmacists review postoperative patients who are well with stable chronic medical conditions and nutritional status together with the endocrinologist and advanced practice nurse (APN). They can prescribe supplements and long-term medications for patients based on blood test results and parameters. They educate patients on the usage and need for medications and supplements.
Specialty Nurses
Nurses provide counselling perioperatively for patients in clinics and wards. They build rapport with patients and manage their care with the multidisciplinary team to improve long-term health outcomes.
Clinical Coordinators
Coordinators vet and manage new referrals to the Obesity Centre. They also manage stable patients in coordinator clinics for weight management.
A track record of excellence Weight management services have been offered at SGH since the 1990s. However, in the early days, these patients were seen by physicians in endocrinology clinics and then referred to ad-hoc sessions with dietitians and/or physiotherapists on different days and at alternate sites. In 2006, obesity services were consolidated in the Diabetes Centre where patients could have concurrent sessions with an endocrinologist, dietitian and coordinator. Subsequently, the LIFE Centre was officially opened by the then Minister of Health, Mr Khaw Boon Wan, on 18 February 2008 as a centre where both the obesity and eating disorder services
were offered in SGH. Coordinated multidisciplinary care is paramount to the care of a patient suffering from obesity. LIFE Centre set the standard with a one-stop service for the management of patients with obesity, with a dedicated team of physicians, dietitians, physiotherapists and psychologists. Setting standards in obesity care Inducted in February 2020, the SGH Obesity Centre enables the hospital to fulfil our national role as the nation battles with the increasing prevalence of obesity and its related diseases. The established Centre extends the good work done by the previous Obesity and Metabolic Unit (OMU) housed in LIFE Centre. The SGH Obesity Centre strives to be at the forefront of innovative obesity care and provides holistic treatment for patients suffering from obesity. Committed to providing a one-stop service for patients, the Centre houses a dedicated team of clinicians (endocrinologists, bariatric surgeons and gastroenterologists), nurses and allied health professionals (AHPs) to provide coordinated multidisciplinary care for obese patients. This allows the team to extend holistic clinical services to patients (from lifestyle modification, to weight loss pharmacotherapy and bariatric surgery) and further treat complex cases as a united multidisciplinary team. |
GPs ROLE IN TREATMENT
Pre-care
GPs in Singapore are well placed to manage metabolic diseases associated with obesity. A subset of more complex patients may require the multidisciplinary care that the SGH Obesity Centre offers.
If GPs feel that their patients require a more focused and comprehensive approach to managing obesity, they may refer them to the SGH Obesity Centre for further management.
Ongoing care
The specialists in the Centre welcome collaboration with the patients’ GPs to provide the best care possible.
Patients may choose to continue follow-up with their GP for the management of chronic medical conditions such as diabetes, hypertention and hyperlipidaemia. These patients often continue to do their usual lab tests and receive medications at their GP, and thus only see the Centre’s specialists once annually. The patients then undergo scheduled follow-up with the AHPs at the Centre, while they continue to see their own GP at regular intervals.
Post-care and shared care
Once a patient has achieved his or her weight loss goal, he or she can be discharged from the Centre. They can then follow up with their own GP for weight maintenance and other medical issues. However, they can choose to see the specialist on an annual basis to ‘check in’. They may also choose to continue seeing the AHPs as needed.
Most bariatric surgery patients follow up with the SGH Obesity Centre’s specialists at regular intervals for the first two years after surgery. After this, they often may only come in for an annual visit and see their own GP for weight maintenance and other medical issues.
However, if patients need more specialised care, they may continue to see one or more specialists at the Centre and the patients’ GPs are updated regularly through correspondence letters.
Dr Sonali Ganguly obtained her Bachelor of Science from Duke University in 1997 and her Doctor of Medicine from West Virginia University School of Medicine in 2001. In 2004, she completed her training in Internal Medicine at Thomas Jefferson University Hospital in Philadelphia, USA. She then did a clinical fellowship in Endocrinology, Diabetes, and Metabolism at the University of Pittsburgh Medical Center in Pittsburgh, USA.
Dr Ganguly is double-board certified in Internal Medicine and Endocrinology, Diabetes, and Metabolism by the American Board of Internal Medicine. She is a Senior Consultant with the Department of Endocrinology and the Director of the Obesity Centre at Singapore General Hospital. She also serves as an Assistant Professor at Duke-NUS Medical School in Singapore. Her main interests are in obesity and diabetes.
Dr Lee Phong Ching is a Consultant Endocrinologist at Singapore General Hospital. In 2016, he spent a year-long clinical fellowship at the Baker Heart and Diabetes Institute in Melbourne, with a focus on clinical obesity research and anagemment. His area of clinical interest is in obesity and its clinical, psychological and social impact on health and is well published in this field.
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