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Obesity is a chronic disease in which the abnormal or excessive accumulation of body fat leads to impaired health and increased risk of mortality and chronic health complications. Prevalence of obesity is rising rapidly in South and Southeast Asia, with potentially serious consequences for local economies, healthcare systems, and quality of life. Our group of obesity specialists from Bangladesh, Brunei Darussalam, India, Indonesia, Malaysia, Philippines, Singapore, Sri Lanka, Thailand, and Viet Nam undertook to develop consensus recommendations for management and care of adults and children with obesity in South and Southeast Asia. To this end, we identified and researched 12 clinical questions related to obesity. These questions address the optimal approaches for identifying and staging obesity, treatment (lifestyle, behavioral, pharmacologic, and surgical options) and maintenance of reduced weight, as well as issues related to weight stigma and patient engagement in the clinical setting. We achieved consensus on 42 clinical recommendations that address these questions. An algorithm describing obesity care is presented, keyed to the various consensus recommendations.

Purpose Obesity increases the risk of incident chronic kidney disease (CKD) and is one of the strongest risk factors for new-onset CKD even in the absence of metabolic risk factors. Weight loss has been shown to reduce renal hyperfiltration and proteinuria. Metabolic bariatric surgery (MBS) remains an effective treatment for obesity and its metabolic-related complications. However, literature on its impact on renal function remains limited. Materials and methods This was an observational retrospective study in a tertiary centre in Singapore. MBS cases performed at the centre between 2008 and 2019 were included. The primary outcome measures were estimated glomerular filtration rate (eGFR), calculated using the CKD epidemiology collaboration equation, and albuminuria (defined as urine albumin-creatinine ratio (uACR) > 3.5 mg/mmol) at baseline and 1-year post-MBS. Results Five hundred fifty-seven patients were included. One-year post-MBS, median eGFR increased from 110.9 mL/min/1.73 m2 (IQR 92.4 to 121.5) to 112.6 mL/min/1.73 m2 (IQR 97.3 to 122.3), p Conclusions MBS had a positive impact on renal function with modest but statistically significant improvement in eGFR and reduction in albuminuria at 1-year post-surgery. Longer-term data is required to investigate the durability of this impact.

ObjectivesTo estimate the incremental per capita and aggregate direct and indirect costs of excess weight among older adults (aged 40–80) in Singapore.DesignSecondary data analysis of an existing cross-sectional surveySettingResidential districts in South-West SingaporeParticipants5848 older adults (aged 40–80) from Singapore’s three dominant ethnic groupsPrimary and secondary outcome measuresWe used regression models to estimate per capita medical expenditures and absenteeism costs attributable to overweight and obesity based on WHO’s body-mass index (BMI) classification. Per capita estimates were multiplied by prevalence to obtain aggregate costs.ResultsThe sample included 2467 Chinese, 2128 Indians and 1253 Malays. Indians and Malays are three to four times more likely to be obese (BMI≥30 kg/m2) than Chinese. Among Chinese, compared with those who are normal weight, individuals who are overweight missed one additional workday per year more (pConclusionExcess weight imposes a substantial health and economic burden among older Singaporeans. Successful efforts to prevent and reduce obesity prevalence may generate both health and economic improvements.

When governments and healthcare providers offer people cash rewards for weight loss, an assumption is that cash rewards are versatile, working equally well for everyone – for example, for all genders. No research to date has tested for gender difference in response to financial incentives for weight loss. We show in an randomized controlled trial (RCT) (n = 472) that cash incentives for weight loss only worked for males. The RCT consisted of a 3-month, self-administered online weight loss program. Offering a US$150 incentive for a 5% weight loss more than tripled the proportion of males who were successful, compared with a no-incentive Control arm (20.9% vs. 5.9%). On average, males in the incentive arm lost 2.4% of weight over 3 months, compared with 0.9% in the Control arm. The same incentive had no such effect on females: The average weight loss in the incentive arm was not significantly different than in the Control (1.03% and 1.44%, respectively), nor was the proportion of participants meeting the 5% weight loss goal (8.6% and 8.7%, respectively). This study shows that males respond better than females to financial incentives for weight loss.

The adverse implications of obesity extend beyond physical health to include negative impact on quality of life (QoL), mood, and eating habits. While bariatric surgery provides successful weight loss and metabolic benefits, studies describe conflicting results on QoL and mood-related outcomes. Patients (n = 140) with class II/III obesity and T2DM were recruited from 2015 to 2019, and stratified based on medical or surgical treatment. Questionnaires including the Hospital Anxiety and Depression Scale, Euro QoL visual analogue scale (EQ-VAS), and Revised 21-item Three-Factor Eating Questionnaire (TFEQ-R21) were recorded at baseline, 6 months, and 12 months after treatment. At baseline, the surgical group (n = 55) and medical group (n = 85) had no significant difference in questionnaire outcomes. At 6 and 12 months, EQ-VAS was higher in the surgical group (12 months surgical 82.00 ± 12.64, medical 72.81 ± 16.56, p = 0.001), with greater improvement from baseline. HADS-D scores at 12 months were lower in the surgical group (surgical 2.60 ± 2.88, medical 3.90 ± 3.58, p = 0.025). At 12 months, the surgical group also had better TFEQ-R21 scores, with higher cognitive restraint scores (surgical 19.09 ± 3.00, medical 16.69 ± 3.61, p

Data on attitudes and perceptions towards obesity are lacking in Asia. Participants who attended an obesity public forum were surveyed concerning obesity and its treatment options. Although obesity is generally accepted as a disease with biological underpinnings such as hormonal imbalances and slow metabolic rate, it is also regarded as an issue of personal responsibility. 65.1% believed that weight-loss medications are dangerous. 20.6% thought that pharmacotherapy is effective for weight loss, whereas 41.1% were unsure. Most believed that bariatric surgery could improve health (81.9%) and diabetes control (74.0%) although 64.1% were unsure of its risks.

Obesity plays a pivotal role in the pathogenesis of obstructive sleep apnea (OSA) and as an exacerbating factor of OSA. Given the interlinking relationship of obesity and OSA, treatment of obesity is fundamental in the management of OSA. Weight loss of 7% to 11% significantly improves OSA with remission seen with greater weight loss. Weight loss also ameliorates the constellation of other obesity-related metabolic conditions, reducing the overall cardiovascular risk in an obese person with OSA. This article discusses specific weight loss interventions effective in improving OSA, including lifestyle interventions with dietary modification and physical activity, pharmacotherapy, and bariatric surgery.

Key Points Question Are bariatric interventions associated with serum micronutrients and metabolic hormones changes in the years after intervention, and do trajectories differ between laparoscopic sleeve gastrectomy vs gastric bypass procedures? Findings In this comparative effectiveness study of 499 patients who underwent sleeve gastrectomy and 189 patients who underwent one-anastomosis or Roux-en-Y gastric bypass, parameters associated with calcium metabolism did not differ between the groups. The extent of hemoglobin suppression was greater among patients who underwent gastric bypass compared with those who underwent laparoscopic sleeve gastrectomy, but the difference was not explained by differences in iron stores or vitamin B levels. Meaning The findings of this study suggest that micronutrient deficiencies after bariatric interventions are differentially associated with types of bariatric procedures., This comparative effectiveness study examines the association of bariatric interventions with micronutrient deficiencies and endocrine disturbances., Importance Few studies have described the longitudinal trajectories of serum levels of micronutrients whose deficiencies are associated with serious sequelae following bariatric procedures, such as anemia, osteoporotic fractures, and neuropathies. Furthermore, previous studies comparing laparoscopic sleeve gastrectomy (LSG) vs Roux-en-Y gastric bypass (LRYGB) or one-anastomosis gastric bypass (OAGB) procedures may have been limited by selection and confounding biases. Objective To appraise the spectrum and temporal course of micronutrient deficiencies associated with bone metabolism and erythropoiesis after LSG vs OAGB or LRYGB procedures, using the propensity score as a balancing score. Design, Setting, and Participants This prospective, longitudinal comparative effectiveness study was conducted at a high-volume bariatric unit in Singapore from September 1, 2008, to November 30, 2017, with a cutoff date for analysis of September 2018. Patients who underwent adjustable gastric banding, biliopancreatic diversion procedures, and intragastric balloon procedures were excluded. All other patients who underwent bariatric procedures were included. Data were analyzed from September 23 to 30, 2018. Main Outcomes and Measures Serial assessment of 13 biochemical parameters at 12 time points for up to 5 years after bariatric procedure. Inverse probability-of-treatment weights were used to obtain estimates of the mean associations of variables assessed with the bariatric surgical interventions. Longitudinal trajectories were analyzed using mixed-effects generalized linear models to apportion the temporal variation of serum micronutrients into fixed-effects and random-effects components. Results A total of 688 patients were included in this study, of whom 499 underwent LSG (mean [SD] age, 41.5 [11.3] years; 318 [63.7%] women) and 189 underwent OAGB or LRYGB (mean [SD] age, 48.6 [9.4] years; 112 [59.3%] women). There were no differences during follow-up among patients who underwent LSG vs those who underwent OAGB or LRYGB in intact parathyroid hormone levels (mean difference, 7.05 [95% CI, −28.67 to 42.77] pg/mL; P = .70), serum 25-hydroxyvitamin D levels (mean difference, −0.72 [95% CI, −1.56 to 0.12] ng/mL; P = .09), or phosphate levels (mean difference, 0.006 [95% CI, −0.052 to 0.064] mg/dL; P = .83). Hemoglobin levels were a mean 0.63 (95% CI, 0.41 to 0.85) g/dL higher among patients who underwent LSG compared with those who underwent OAGB or LRYGB (P

Laparoscopic sleeve gastrectomy (LSG) has become the preferred bariatric procedure in many countries. However, there is one shortcoming of LSG in the long-term follow-up and this is the onset of GERD and erosive esophagitis (EE). Current evidence of the effect of SG on GERD did not consolidate to a consensus. In this study, we objectively evaluate the incidence of EE 1 year post-LSG with upper endoscopy (EGD) and try to identify the significant variables and possible underlying mechanisms of the EE post-LSG. Over a period of 5 years (2011–2016) at Singapore General Hospital, we retrospectively reviewed a prospectively collected database of a cohort of patients whom had LSG by a single surgeon who routinely performed EGD pre-operative and 1 year post-operative to assess EE and hiatal hernia. Patient’s endoscopic findings and demographic and anthropometric data were analyzed. We identified a total of 97 obese patients who underwent LSG at our hospital by studied surgeon. Sixty-three patients (64.9% of original sample) were finally evaluated in the present study, 40 (59.7%) of whom were female. The mean (range) age of patients was 38.2 (18–66) years, and mean BMI was 36.3 ± 4.1 kg/m2. Median time to follow-up EGD was 13 months (range, 12–15). Following LSG, there was a significant decrease in both BMI (42.1 ± 1.2 vs. 29.9 ± 1.0 kg/m2) and percentage excess weight loss of 56.6 ± 3.6%. The prevalence of EE on endoscopy increased from 9 (14.3%) to 28 (44.4%) patients. Of which 15 (23.8%) were grade A, 11 (17.5%) were grade B, and 2 (3.2%) were grade C. There was no correlation between GERD symptoms with EE; however, our study found a trend suggesting higher prevalence of EE with a sleeve diameter measuring > 2 cm wide (p = 0.069). Although LSG is effective in treating obesity and its metabolic syndromes, the prevalence of EE increased significantly 1 year after the surgery. Since we do not fully understand the long-term impact of chronic esophagitis in post-sleeve population, we recommend follow-up EGD assessment post-operatively and treat the esophagitis if present.

INTRODUCTION Obesity is a key risk factor in the development of Type 2 diabetes mellitus (T2DM). Bariatric surgery causes a large amount of durable weight loss in those with clinically severe obesity. We reported the effect of weight loss via bariatric surgery on DM prevention in those at high risk of developing DM. METHODS This was a retrospective cohort study of 44 patients with obesity (mean body mass index 43.8 kg/m2) and pre-DM who underwent bariatric surgery and were followed up for up to three years. We also reviewed a non-surgical cohort of patients with obesity and pre-DM seen at the weight management clinic. RESULTS 91% of patients attained normal glycaemic status at one year after bariatric surgery. At the three-year follow-up, 87.5% of the patients maintained normoglycaemia. None of the patients developed T2DM after surgery. 26.9% of patients achieved absolute weight loss at one year after bariatric surgery and maintained this at two and three years post surgery (p < 0.001 vs. baseline). The homeostatic model assessment-insulin resistance index in patients also decreased from 5.50 at baseline to 1.20, 1.14 and 1.44 at one, two and three years, respectively (p < 0.001). CONCLUSION Bariatric surgery produces significant weight loss, and leads to reversion from the pre-diabetic state to normal glycaemic status and reduction of the incident DM rate in those with pre-DM and morbid obesity.

In Asia, metabolic-bariatric surgery (MBS) rates have grown rapidly in parallel with rising prevalence of obesity and type 2 diabetes (T2D). The objective of this study was to identify factors that influence glycemic outcomes and diabetes remission 12 months after sleeve gastrectomy (SG) or gastric bypass (GB) in a multiethnic Asian cohort. The study’s setting was in a tertiary hospital in Singapore. Data from 145 T2D patients who had SG (37%) or GB (63%) and at least 1-year follow-up were analyzed. Diabetes remission was defined as hemoglobin A1c ≤ 6.0% without diabetes medications. Analysis involved binary logistic regression to identify predictors and general linear regression for variables associated with glycemic improvement after surgery. Baseline parameters are as follows: BMI 40.0 ± 7.6 kg/m2, A1c 8.4 ± 1.6%, diabetes duration 9.3 years, ethnic composition: Chinese (51.7%), Malay (23.4%), Indian (20.7%), Others (4.1%). 55.9% achieved diabetes remission at 1 year. Baseline A1c, baseline BMI, and diabetes duration were significant pre-operative factors for remission (cumulative R 2 = 0.334). At 12 months, percentage weight loss was similar after SG (24.1 ± 7.4%) and GB (25.4 ± 7.4%, p = 0.31). Greater A1c decrease was seen with GB compared to SG (2.7 ± 1.6 vs 2.0 ± 1.5%, p = 0.006), significant even after adjustment for weight loss, age, BMI, baseline A1c, and diabetes duration (p = 0.033). Weight loss at 12 months also correlated independently with A1c reduction. Ethnicity did not influence weight loss, diabetes remission, or glycemic control after MBS. Baseline A1c, baseline BMI, and diabetes duration independently predict diabetes remission after MBS. GB is more effective in controlling T2D compared to SG despite similar weight loss, whereas ethnicity does not play a significant role in the multiethnic Asian cohort.

Introduction: Obesity increases the risk of incident chronic kidney disease (CKD), being one of the strongest risk factors for new-onset CKD even in the metabolically normal obese. Weight loss has been shown to reduce renal hyperfiltration and proteinuria. Metabolic Bariatric Surgery (MBS) remains an effective treatment for obesity and its metabolic related complications. However, literature on its impact on long term renal function remains limited. Methods: This was an observational retrospective study in a tertiary centre in Singapore. MBS cases performed at the centre between 2008 and 2019 were included. The primary outcome measure was estimated Glomerular Filtration Rate (eGFR), calculated using the CKD Epidemiology Collaboration equation, and albuminuria (defined as urine Albumin-Creatinine Ratio (uACR) >3.5 mg/mmol) at baseline and at one-year post surgery. Results: 557 patients were included. Baseline parameters are as follows: mean age 41.7 ±10.1 years; female 65.4%; ethnic composition: Chinese (35.2%), Malay (33.0%), Indian (26.9%); BMI 42.5 ±7.9 kg/m²; glycaemic status: Diabetes Mellitus (34.5%), Pre-diabetes (13.5%), Non-diabetic (52.1%); Hypertensive status: Hypertension (55.2%), Pre-Hypertension (1.9%), Normotensive (42.9%). Median eGFR was 110.9 (92.4 - 121.5) mL/min/1.73 m² and median uACR was 1.00 (0.40 - 3.55) mg/mmol. At one-year post surgery, patients achieved statistically significant reductions in mean BMI (-11.3 ±4.2 kg/m2), systolic BP (-3.24 ±19.3 mmHg), diastolic BP (-5.23 ±13.8 mmHg), fasting glucose (-1.95 ±2.89 mmol/L) and improvement in HDL (0.29 ±0.26 mmol/L). In addition, statistically significant reductions in the proportion of patients on anti-hypertensive (48.8% to 14.4%), anti-diabetic (34.1% to 12.7%) and lipid-lowering medications (37.8% to 20.4%) were seen. In particular, ACE-inhibitor and/or angiotensin receptor blocker (32.9% to 9.2%, p< 0.001) usage was reduced. At one-year post surgery, median eGFR increased by 1.66 mL/min/1.73 m² (p Conclusions: Metabolic bariatric surgery had a positive impact on renal function as shown by the improvement in eGFR in the non-diabetic group, and the reduction in albuminuria in the diabetes and pre-diabetes group at one-year post surgery. More adequately powered, longer-term data is required to investigate the durability of this impact.

Obesity plays a pivotal role in the pathogenesis of obstructive sleep apnea (OSA) and as an exacerbating factor of OSA. Given the interlinking relationship of obesity and OSA, treatment of obesity is fundamental in the management of OSA. Weight loss of 7% to 11% significantly improves OSA with remission seen with greater weight loss. Weight loss also ameliorates the constellation of other obesity-related metabolic conditions, reducing the overall cardiovascular risk in an obese person with OSA. This article discusses specific weight loss interventions effective in improving OSA, including lifestyle interventions with dietary modification and physical activity, pharmacotherapy, and bariatric surgery.

Obesity-induced insulin resistance leads to abnormalities in glucose, lipid, and amino acid metabolism. Our study examined the differences in insulin-mediated glucose, amino acid, and lipid metabolism between morbidly obese subjects with non-obese controls and the associated changes following sleeve gastrectomy (SG). Non-obese controls and individuals with morbid obesity and scheduled for SG were recruited. Metabolic assessments were performed for all subjects at baseline and at 6 months after SG for eight subjects. The hyperinsulinemic-euglycemic clamp technique together with comprehensive metabolomic profiling was used to quantify insulin-mediated glucose, amino acid, and lipid metabolism. Eleven morbidly obese non-diabetic subjects scheduled for SG and nine non-obese controls were recruited. Compared to controls, obese subjects had significantly lower glucose uptake (4.4 ± 0.6 vs. 17.3 ± 2.4 mg/kg FFM/min per μU/mL·100) and higher concentration of branched-chain amino acids (BCAAs, 332.5 ± 26.8 vs. 235.3 ± 11.0 μM), non-esterified fatty acid (52.9 ± 9.9 vs. 25.6 ± 6.7 μM), and lipid-related acylcarnitines (intermediate chain 389.8 ± 32.5 vs. 285.9 ± 20.5; long chain 301.7 ± 22.1 vs. 236.0 ± 13.3 nM) during insulin clamp. Body weight significantly reduced at 6 months after bariatric surgery (92.5 ± 6.3 vs. 115.2 ± 6.9 kg), together with improvements in insulin-mediated glucose uptake, and suppression of BCAAs, non-esterified fatty acids, and lipid-related metabolites. Morbid obesity in Asian individuals was associated with impairment in the regulatory actions of insulin on glucose, amino acid, and lipid metabolism, and these obesity-induced regulatory dysfunctions improved significantly 6 months after SG.

Background: Metabolic-bariatric surgery (MBS) leads to durable weight loss and significant metabolic improvement in type 2 diabetes mellitus (T2DM) patients with obesity. However, data on durability of control is often lacking in Asia. Aim: We report 5-year glycemic and metabolic outcomes in a T2DM cohort who had MBS from 2008-2012 at a tertiary center in Singapore. Methodology: Patient demographics and biochemical parameters were retrieved from a web-based data repository. DM remission was defined as HbA1c ≤6% without DM medications. Results: There were 59 patients with a mean age of 43.0±9.5 years and 37.3% were males (Table 1). Most (76.3%) had gastric bypass while 23.7% had sleeve gastrectomy. Baseline mean weight and BMI were 114.4±27.4 kg and 42.5±10.5 kg/m2 respectively. Mean weight loss of 26% was achieved at 1 year and sustained over 5 years. Mean HbA1c decreased from 8.3% to 5.8% and 6.3% at 1 and 5 years respectively, with use of fewer DM, anti-hypertensive and lipid-lowering medications. At 5 years, 18 of 43 (41.9%) patients achieved sustained remission of diabetes with 6 (14.0%) having relapse of DM after initial remission at 1 year. Conclusion: MBS is effective therapy for obesity and DM with durable glycemic and metabolic control associated with lower medication use over 5 years in this Asian population.Table 1. Characteristics of subjects at baseline and over 5-year follow upPatient characteristicsPre-surgery (n=59)12 months (n=47)24 months (n=40)36 months (n=37)48 months (n=38)60 months (n=43)GenderMaleFemale22(37.3%)37(62.7%)NANANANANAAge (years)43.0 ± 9.5NANANANANAEthnicityChineseMalayIndianOther24 (40.7%)20 (33.9%)14 (23.7%)1 (1.7%)NANANANANADiabetes mellitus duration (months)92.1±96.3NANANANANATypes of surgerySleeve gastrectomyMini gastric bypassRoux-en-Y gastric bypass14(23.7%)16(27.1%)29(49.2%)NANANANANAWeight (kg)114.4±27.484.9±20.5*84.5±21.0*87.5±23.0*83.0±19.9*83.8±21.5*Body Mass Index (BMI) (%)42.5±10.531.9±8.3*31.3±7.4*32.5±8.2*31.3±8.06*32.0±8.67*Systolic blood pressure (mmHg)127.0±14.6125.6±17.3125.8±18.2130.2±17.7129.7±13.3135.4±19.2Diastolic blood pressure (mmHg)77.0±9.577.5±11.878.3±10.880.5±8.778.8±10.775.8±8.7Fasting blood glucose (mmol/L)8.51±3.125.51±1.93*5.99±2.11*6.59±2.57*6.72±2.51*6.73±2.55*HbA1c (%)8.32±1.385.82±0.82*6.09±1.09*6.51±1.31*6.53±1.11*6.32±1.02*Lipid panel (mmol/L)Total cholesterolLDLTriglycerideHDL4.56±0.882.75±0.811.69±0.741.05±0.264.77±0.942.83±0.611.19±0.56*1.32±0.29*4.81±0.77*2.84±0.731.30±0.51*1.46±0.54*4.79±0.86*2.78±0.701.42±0.68*1.37±0.32*4.54±0.912.52±0.801.41±0.76*1.38±0.28*4.17±0.522.28±0.451.30±0.70*1.30±0.28*Number of DM medications1.90±1.030.42±0.79*0.31±0.68*0.45±0.93*0.57±1.10*0.60±1.19*Antihypertensive medications1.64±1.210.42±0.70*0.39±0.72*0.37±0.79*0.40±0.83*0.45±0.95*Lipid-lowering medications0.81±0.570.17±0.38*0.25±0.44*0.31±0.50*0.27±0.49*0.33±0.51*Diabetes remission (n)NA2824121218Continuous data as mean ± SD; categorical data as n (%)* Presence of significant difference when compared to pre-surgery data (p Disclosure Z. Liew: None. A. Maung: None. S. Ganguly: Advisory Panel; Self; Novo Nordisk Inc.. P. Lee: None. K. Tham: None.

Post-operative bleeding is a major but infrequent complication in laparoscopic sleeve gastrectomy (LSG). There is paucity in the literature on management of this complication. This paper seeks to review the presentation of post-operative bleeding complications after LSG in a single cohort of patients and highlight the surgical and non-surgical methods of treatment. A retrospective study of 409 LSG patients performed in a tertiary hospital, Singapore General Hospital (SGH) since 2008. Patients who encountered post-operative bleeding complications, defined as requiring blood transfusion or re-laparoscopy for haemostasis, were identified from a prospectively recorded database. The presentation, source of bleeding and management were recorded and presented. Five out of 409 (1.2%) patients were diagnosed with post-operative bleeding. Two patients were treated conservatively requiring only blood transfusion and 3 patients were surgically explored with laparoscopy, 2 were from staple line bleeding (SLB) and suture haemostasis performed. In 1 patient, the source of bleeding was not identified intraoperatively and CT angiography performed post-operatively showed active contrast bleeding near short gastric arteries and gastroepiploic artery. Gel foam and coil embolization was performed and the bleeding was controlled. Average hospitalization stay due to post-operative bleeding was 7.3 days compared to 2.3 days for those without. Post-operative bleeding after LSG occurred at the staple line and branches of the right gastro-epiploic artery and short gastric arteries. Bleeding may stop spontaneously or require haemostasis by operative or endovascular means. CT angiogram is proposed to locate the source of bleed and subsequent embolization of bleeding arteries maybe possible, avoiding the need for re-operation. Bleeding from the staple line requires surgical haemostasis.

INTRODUCTION: Obesity is a risk factor for type 2 diabetes mellitus (T2DM). Metabolic-bariatric surgery (MBS) results in significant weight loss with dramatic improvement in T2DM. This study analysed the effects of MBS on patients with T2DM in a tertiary centre in Singapore. METHODS: Individuals with T2DM who underwent MBS in a single centre from September 2008 to May 2012, with at least 12 months of regular follow-up, were included in our study. The primary outcome measure was good glycaemic control (glycated haemoglobin [HbA1c] < 6.5%, with or without medications) 12 months after surgery. Secondary outcome measures were partial DM remission (fasting blood glucose [FBG] < 7.0 mmol/L and HbA1c < 6.5% without DM medications), complete DM remission (FBG < 5.6 mmol/L and HbA1c < 6.0% without DM medications), weight, body mass index, blood pressure, and fasting serum lipid, serum glucose and serum insulin levels. RESULTS: Of the 19 patients who met the inclusion criteria, 14 underwent gastric bypass and 5 underwent sleeve gastrectomy. At 12 months postoperatively, 17 (89.5%) patients achieved good glycaemic control. DM remission was achieved in 14 (73.7%) patients, with 10 (52.6%) attaining complete remission. CONCLUSION: In Singapore, MBS is an effective treatment modality for obese patients with T2DM. Despite the small sample size and lack of matched controls, the present study suggests that MBS is effective in achieving significant weight loss and eliciting a significant and sustainable improvement in the glycaemic control of patients with T2DM, for up to 12 months.

The prevalence of overweight and obesity has more than doubled in the past three decades, leading to rising rates of non-communicable diseases. This study tests whether adding a payment/rewards (term reward) program to an existing evidence-based weight loss program can increase weight loss and weight loss maintenance. We conducted a parallel-group randomized controlled trial from October 2012 to October 2015 with 161 overweight or obese individuals randomized to either control or reward arm in a 1:2 ratio. Control and reward arm participants received a four month weight loss program at the LIFE (Lifestyle Improvement and Fitness Enhancement) Centre at Singapore General Hospital. Those in the reward arm paid a fee of S$165.00 (1US$ = 1.35S$) to access a program that provided rewards of up to S$660 for meeting weight loss and physical activity goals. Participants could choose to receive rewards as guaranteed cash payments or a lottery ticket with a 1 in 10 chance of winning but with the same expected value. The primary outcome was weight loss at months 4, 8, and 12. 161 participants were randomized to control (n = 54) or reward (n = 107) arms. Average weight loss was more than twice as great in the reward arm compared to the control arm at month 4 when the program concluded (3.4 kg vs 1.4 kg, p < 0.01), month 8 when rewards concluded (3.3 kg vs 1.8 kg, p < 0.05), and at month 12 (2.3 kg vs 0.8 kg, p < 0.05). These results reveal that a payment/rewards program can be used to improve weight loss and weight loss maintenance when combined with an evidence-based weight loss program. Future efforts should attempt to replicate this approach and identify how to cost effectively expand these programs to maximize their reach. This study is registered at www.clinicaltrials.gov (Identifier: NCT01533454).

The serum metabolomic profile and its relationship to physiological changes during hyperthyroidism and restoration to euthyroidism are not known. This study aimed to examine the physiological, adipokine, and metabolomic changes that occur when subjects with Graves' disease transition from hyperthyroidism to euthyroidism with medical treatment.Chinese women between 21 and 50 years of age and with newly diagnosed Graves' disease attending the endocrine outpatient clinics in a single institution were recruited between July 2012 and September 2014. All subjects were treated with thioamides to achieve euthyroidism. Clinical parameters (body weight, body composition via bioelectrical impedance analysis, resting energy expenditure and respiratory quotient via indirect calorimetry, and reported total energy intake via 24 h food diary), biochemical parameters (thyroid hormones, lipid profile, fasting insulin and glucose levels), serum leptin, adiponectin, and metabolomics profiles were measured during hyperthyroidism and repeated in early euthyroidism.Twenty four Chinese women with an average age of 36.3 ± 8.6 years were included in the study. The average duration of treatment that was required to reach euthyroidism for these subjects was 38 ± 16.3 weeks. There was a significant increase in body weight (52.6 ± 9.0 kg to 55.3 ± 9.4 kg; p 0.001) and fat mass (14.3 ± 6.9 kg to 16.8 ± 6.5 kg; p = 0.005). There was a reduction in resting energy expenditure corrected for weight (28.7 ± 4.0 kcal/kg to 21.5 ± 4.1 kcal/kg; p 0.001) and an increase in respiratory quotient (0.76 to 0.81; p = 0.037). Resting energy expenditure increased significantly with increasing free triiodothyronine levels (p = 0.007). Significant increases in total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol were noted. There was no significant change in leptin levels, but adiponectin levels increased significantly (p = 0.018). Significant reductions in fasting C2, medium-chain, long-chain, and total acylcarnitines were observed, but no changes in the fat-free mass, branched chain amino acid levels, or insulin sensitivity during recovery from hyperthyroidism were noted.Serum metabolomics profile changes complemented the physiological changes observed during the transition from hyperthyroidism to euthyroidism. This study provides a comprehensive and integrated view of the changes in fuel metabolism and energy balance that occur following the treatment of hyperthyroidism.

Weight loss, early after Roux-en-Y gastric bypass (GB) surgery, is associated with reduced concentrations of plasma branched-chain amino acids (BCAAs) and improved insulin sensitivity. Herein, we evaluated whether changes in BCAAs and insulin sensitivity persist with weight stabilization (1 year) after GB or sleeve gastrectomy (SG). We prospectively examined 22 severely obese patients (mean age 40.6 ± 2.1 years, BMI 38.8 ± 1.3 kg/m2, and 59.1 % female) who underwent SG (n = 12) or GB (n = 10) for morbid obesity. Body fat composition was measured with dual X-Ray absorptiometry and abdominal fat volume with computed tomography. BCAAs and acylcarnitines were profiled using liquid chromatography with tandem mass spectrometry. Insulin resistance was calculated using the homeostasis model assessment for insulin resistance (HOMA-IR) formula. At 1-year follow-up, the decrease in BMI, body weight, total fat mass (TFM), fat free mass, and visceral adipose tissue (VAT) was similar between SG and GB. HOMA-IR was associated with BCAA concentrations, and both were decreased equally in both surgical groups. In multivariate analysis with BCAAs, TFM, and VAT as independent factors, only VAT remained significantly associated with insulin resistance. The metabolic benefits from bariatric surgery, including the changes in BCAA profile, are comparable between SG and GB. The reduction in BCAAs and improvement in the AC profiles after bariatric surgery persists up to 12 months after surgery and may not be surgical related but is influenced primarily by the amount of weight loss, in particular the reduction in visceral adiposity.

Objectives Previous studies reveal that the Three-Factor Eating Questionnaire (TFEQ), which assesses eating behaviour, performs differently across population groups and cultures. We aimed to identify the factor structure that is most appropriate to capture eating behaviour in an overweight and obese Chinese population in Singapore. Methods TFEQ-51 was administered to 444 Chinese subjects pooled from four separate studies and scored according to various alternative versions of the TFEQ. Confirmatory factor analyses and goodness of fit indices were used to determine the most appropriate factor structure. Known-group validity analyses were conducted. Results Niemeier's Disinhibition Factors and the TFEQ-R18 factor structures were found to be the most applicable in our population based on goodness of fit indices, with a x2/df ratio of 0.9 for both. Only two of three factors (Emotional Eating and Uncontrolled Eating) of the TFEQ-R18 showed good internal consistency, while none of Niemeier's Disinhibition Factors showed good internal consistency. Known-group validity showed that Emotional Eating and Internal Disinhibition were significantly associated with higher BMI. Conclusion We found that the TFEQ-R18 factor structure is the most appropriate and practical for use in measuring eating behaviour in an overweight and obese Chinese population in Singapore.

Restless legs syndrome (RLS) is a poorly understood sleep-related movement disorder which can be primary or associated with other conditions, most commonly iron deficiency, uremia and peripheral nerve disease. We present a case of RLS with an unusual secondary cause: primary hyperparathyroidism with hypercalcemia. This patient experienced complete and sustained relief of RLS symptoms immediately after parathyroidectomy, with normalization of her serum parathyroid hormone (PTH) and calcium levels. Early recognition and treatment of this uncommonly detected underlying cause is important because it is potentially curative in this frequently disabling condition for which usually only symptomatic treatment is available.

Introduction: Comprehensive sleep architecture and respiratory event data in local patients with suspected obstructive sleep apnoea (OSA) from overnight polysomnography (PSG), the gold standard for the evaluation of sleep-related breathing disorders, are not widely available. We present 1 year retrospective PSG data with the objective of describing PSG characteristics of patients evaluated for OSA in Singapore. Materials and Methods: PSG data of patients evaluated for OSA in 1 year (January through December 2005) in the Sleep Laboratory of a public tertiary hospital were retrospectively reviewed. Results: Five hundred and eighty-four diagnostic PSG studies were performed in patients with symptoms suggestive of sleep-disordered breathing, including snoring, excessive daytime sleepiness, unrefreshing sleep, or recurrent unexplained awakenings. There were 449 male patients (76.9%) and 135 female patients (23.1%), with a mean age of 47.5 years (SD 12.7). Men were on average younger than women, 46.1 years versus 52.0 years (P 15-30 (“Moderate”) (18.3%), AHI >30 (“Severe”) (31.2%). There was no significant age difference among the 4 groups. More severe OSA patients were significantly heavier, and had more light sleep, less deep sleep, less REM sleep, more respiratory event related arousals and lower levels of oxygen desaturation. Conclusion: OSA is predominant in middle-aged, overweight Singapore males and much less common in females who tend to be older. A majority of patients have moderate to severe OSA, which significantly disturbs normal sleep architecture. The relatively lower BMI compared to Caucasian OSA populations may be related to local craniofacial characteristics and/or higher percentage of body fat for BMI which has been described in Singaporeans. Key words: Body-mass index, Obstructive sleep apnoea (OSA), Polysomnography (PSG), Sleep architecture