What would Einstein say?

It only took 15 years, but Singapore Health Ministers have finally chucked their “Trim and Fit” program.

For those unfamiliar with this initiative, it was a comprehensive “healthy lifestyle” promotion launched in 1992 in Singapore public schools, aimed at reducing obesity levels and improving fitness among school children. As the Ministers of Health wrote in a letter in the British Medical Journal, it encompassed everything believed important to reduce obesity and the chronic diseases associated with it: nutrition curriculums, strict control over “unhealthy” foods and drinks available in schools, promoted drinking more water, intensive physical exercise, rewarded healthy lifestyle practices, promoted healthy lifestyle habits in families’ homes, etc. Fat children were given special attention. They were also referred to public health services for “more intensive followup with doctors and dietitians.”

But the reality of life for these heavier children was far from positive. An Associated Press story several years ago described it in more detail:

Singapore takes strict steps against obesity — Overweight kids singled out for extra exercise in school

The fight against obesity starts young in Singapore. Fat children are separated from their classmates and ordered to do more exercising until they lose weight. Ten-year-old Mona Siow has been trying to lose weight for the last four years. Instead of joining her friends at the canteen during recess every day, the fourth-grader and other chubby students gather in the hall and follow a teacher’s instructions to skip rope, run, and dribble a basketball. “I feel sad to be overweight when I look at people and they’re so skinny and can wear so many clothes,” says Siow, who needs to shed about 37 pounds before she can leave the program. At 4 feet 8, she weighs 128 pounds.

As a member of a Singapore primary school’s “Health Club” — where membership is compulsory for overweight kids — Siow does special exercises on top of the regular physical education curriculum. Teachers monitor her height and weight every month....[T]eachers meet her parents regularly to recommend healthier ways to prepare their daughter’s meals at home.

The government created a school-based intervention program that includes rigorous exercise for plump children and recommendations on food sold in canteens...The so-called “health clubs” have reduced the proportion of overweight students from 14 percent in 1992 to 10 percent in 2003, education ministry statistics show, but many, like Siow, don’t shed the pounds. “It’s quite disheartening to see students remain in the club for a number of years,” says Lim Ee Kheng, the school’s head of physical education at Siow’s school, the elite Singapore Chinese Girls’ Primary School... if Siow fails to lose her required weight, she is doomed to stay in the program until she completes her pre-university schooling.

Singapore health ministry figures show that about 6 percent of its 4 million people are obese — at least 30 pounds too heavy....“We noticed that although Singaporeans are less obese compared to people of (other) developed countries, our heart disease trend is similar to theirs,” says Mabel Yap, head of research and information at the government’s Health Promotion Board....Yap has recommended that the country’s health policy-makers lower the BMI at which an [adult] would be considered overweight from 25 to 23. That could lead to as much as half of all the island’s residents being too fat, instead of just 1 in 3. “It’s enough to alarm,” she said.

The Associated Press reported today that the official reason given for disbanning this program was criticism from parents that heavier children were being targeted with ridicule and bullying by their peers. Masagos Zulkifli, senior parliamentary secretary for education, admitted the program stigmatized fat students. Plans are underway for a new program to promote “a healthy lifestyle,” according to the news, but no details have been provided.

Public health officials appear to continue to ignore the evidence surrounding “healthy lifestyle” programs and especially fail to consider the harm resulting from them. Reduced obesity rates do not equate to improved health. For instance, beyond increasing discrimination and stigma suffered by fat children, the Straits Times/Asia News Network reported another troubling trend resulting from accentuated weight concerns among young people and the increased desperation to achieve culturally-acceptable bodies:

Singaporeans among the most weight-conscious

Singapore - Pound for pound, Singaporeans are among the world's most weight-conscious people, says a report on the use of slimming pills. Singapore ranks fifth in per capita usage of appetite-suppressants called anorectics, according to the United Nations report....Yet Singapore's ranking seems out of kilter when its obesity rates are compared with others in the top five.

Brazil has an obesity rate of 13.5 per cent, according to World Health Organisation data...Singapore, in contrast, barely tips the scales at 1.6 per cent.

...Three anorectics available here only by prescription are phentermine (brand names Duromine and Panbesy), mazinol (Teronac) and sibutramine (Reductil). Doctors said more patients wanted help to slim, so more pills might have been prescribed. But medics fear people are taking them just to look good.

According to the deputy and assistant deputy directors of the Minister of Health, Singapore’s "Trim and Fit" healthy lifestyle program was patterned after the school-based Active Programme Promoting Lifestyle Education in School interventions that had been tested in ten schools in Leeds, England, by Pinki Sahota and colleagues.

Let's look at their paper, “Randomized controlled trial of a school-based intervention program to reduce risk factors for obesity” published in the November 2001 issue of the British Medical Journal, which described this comprehensive program. It included “teacher training, modification of school meals, and the development of school action plans targeting the curriculum, physical education, tuck shops, and playground activities.”

How effective did it prove to be?

Their results yielded no difference in body mass index, despite self-reported changes in understanding and knowledge among participating children. After the program, children reported eating about an additional 1/3 portion of vegetables a day, while decreasing fruit servings by one. There were also reductions in overall physical activity levels among the “overweight” children. While denying any psychological harm to the heavier children, the researchers concluded: “Although it was successful in producing changes at school level, the programme had little effect on children’s behaviour other than a modest increase in consumption of vegetables.”

An accompanying editorial in the British Medical Journal by professors at the University of Wisconsin, Madison, entitled “Increase knowledge about nutrition but do not change eating habits by much,” criticized the study authors for underemphasizing the less favorable changes, saying:

To combat this epidemic, educational programmes and policies in schools would seem to be a logical response. Two articles by Sahota et al in this issue examine the Active Programme Promoting Lifestyle Education in School...Their result reveal a paradox: cooperation by parents, teachers, administrators, and children was very good, and their knowledge and awareness about nutrition increased significantly. However, children's nutrition habits changed only slightly, and there were no changes in other outcomes.

On balance, these results suggest that school based prevention programmes have limited potential for curbing the epidemic of obesity among children....Several studies similar to those of Sahota et al have been reported and most have reached similar conclusions....In a literature search dating back to 1965, Story identified 11 such controlled experimental studies. Treatment programmes showed positive, though modest, short term results.

Thus both Sahota et al's study and previous studies show that most school based intervention programmes increase knowledge about nutrition, but they rarely produce significant changes in behaviour or favourable short to intermediate term health outcomes.

The editorial also cautioned that because of the potential to produce more stigmatization and eating disorders, “careful thought and research are needed to identify the most appropriate strategies to treat obesity in children.”

We might ask ourselves, where is the support for the necessity of these massive programs and this degree of panic over the unhealthfulness of today's children? As the U.S. Preventive Service Task Force concluded, there is no longitudinal data relating childhood "obesity" to health outcomes or support for today’s slightly taller and larger children being a concern. Yet, public health officials, healthcare professionals and the enormous throngs of vested interests continue to enact and re-enact “healthy lifestyle” programs for which there is no evidence of effectiveness, and plenty to suggest harm, hoping that magically the outcomes will be different next time.

Insanity: doing the same thing over and over again and expecting different results. — Albert Einstein

© 2007 Sandy Szwarc

[Photo of Trim and Fit program: Wong Maye-e/AP]