Body Mass Index (BMI) Control
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​​Last updated on 18 December 2023

Recent key changes:

  • Updated management section to include diet advice as indicated in Lifestyle Prescription template. 

  • Updated referral criteria for “Red" Segment Programme: Khoo Teck Puat Hospital Integrated Care for Obesity and Diabetes:

Previous Referral Criteria - Khoo Teck Puat Hospital Integrated Care for Obesity and DiabetesUpdated Referral Criteria - Khoo Teck Puat Hospital Integrated Care for Obesity and Diabetes
  • Age 18-65 years old
  • BMI 32.5 to <37.5 with co-morbidities
  • BMI ≥37.5 with or without obesity related co-morbidities
  • Age 18-65 years old
  • BMI ≥32.5 with obesity related co-morbidities
  • BMI ≥37.5 with or without obesity related co-morbidities

(The full list of “Red" Segment Programmes can be found here.)

  • Removed Khoo Teck Puat Hospital Integrated Care for Obesity and Diabetes and Tan Tock Seng Hospital Weight Management Service from table on “Tertiary weight management programmes which accept patients beyond the minimum criteria" as these programmes only accept patients aged 18 – 65 years of age:

Programmes for persons aged >65 years old

NUH Centre for Obesity Management and SurgeryAvailable for all adults
KTPH Integrated Care for Obesity and DiabetesAvailable for all adults
TTSH Weight Management ServiceAvailable for all adults
CGH Sports and Exercise Medicine Weight Management ClinicAvailable for all adults
SGH Obesity Centre Weight Management InterventionAvailable for all adults
Sengkang Weight Improvement Therapy & Complete HealthAvailable for all adults


Updated Sign Up Form for SportSG's Active Health Targeted programmes for Orange programmes, which contains the QR code where patients can register for the programme at their preferred location.


Body Mass Index (BMI) is useful as an initial screening tool to identify enrollees who may have health problems associated with being under or overweight.

The BMI Control Care Protocol is designed for enrollees aged 18 to 65 years old.

Do not use BMI for enrollees aged <18 years old, pregnant women, and very muscular individuals (e.g. athletes). For those aged >65 years old, use BMI with prudence.

​
Measurement and Definition of Body Mass Index (BMI)1​

  1. Measure BMI routinely. Definition of BMI = Weight (kg)/(Height (m) X Height (m))

    • ​BMI cut-off points in Asians​ 

  2. Consider measuring waist circumference

Clinical Assessment1​​

Through a focused history, physical examination, and investigations​​:

  1. Identify possible causes of obesity

  2. Assess risk factors

    • ​Presence of metabolic syndrome​

    • 10-year Coronary Artert Disease (CAD)  risk score

  3. Complications associated with obesity

Waist Circumference​ 

As part of a complete cardiovascular risk assessment, waist circumference measurement is recommended for all enrolees. A high waist circumference ≥90 cm for males and ≥80 cm for females increases the likelihood of adverse cardio metabolic outcomes such as Type 2 Diabetes Mellitus (DM), lipid disorder, or hypertension. Waist circumference will likely be elevated for a BMI of ≥32.5 m2/kg.​​

Definition of Metabolic Syndrome2​

Metabolic syndrome is defined as the presence of any three out of the following five traits:

Table 1: Traits of Metabolic Syndrome

​No.​
 ​Traits​​
 Description​
​1
 ​Abdominal​ obesity
 ​Waist circumference of ≥90 cm in men and ≥80 cm in females (Asian cut-offs)
​2
 ​Triglycerides
 ​≥1.7 mmol/L (150mg/dL)
3​ ​High Density Lipoprotein-Cholesterol (HDL-Cholesterol​)
 ​≤1.0 mmol/L (38 mg/dL) in men or ≤​1.3 mmol/L (50 mg/dL) in women
4​ ​Blood pressure​
 ​≥130/85 mmHg or on treatment for hypertension​​
​5
 ​Fasting plasma glucose
 ​≥6.1 mmol/L (110 mg/dL) or on treatment for diabetes​ mellitus


Presence of metabolic syndrome puts a person at higher risk of developing DM and cardiovascular disease.​

Treatment Goals​1​​

For Asians with BMI of ≥23 kg/m2 and/or high-risk waist circumference, introduce the following where applicable:​

  1. ​Reduce body weight by 5 to 10% over 6 to 12 months
  2. Therapy: diet, exercise​​


Both a healthy diet and physical activity are essential to controlling BMI.

In enrollees with no chronic conditions, GPs may advise them to use My Healthy Plate. 

  1. Substitute ≥20% of refined carbohydrates with wholegrains, and choose lean protein, fresh produce, and healthier oils and fats. 

  2. Reduce salt and sugar intake, and increase soluble fibre consumption.

  3. Older adults should include protein as part of every meal.

For further guidance on nutrition and healthy eating, please refer to the Lifestyle Prescriptions document​.

Physical Activity

Figure 1 below provides a framework to guide GPs on the management approach and programmes that can be recommended to patients aged 18 to 65 years old, depending on their profile. (Some programmes may address diet as well.)

For patients above 65 years old, GPs may examine the history of weight change over their patient's lifetime to gain a more complete understanding of their risk profiles3 ​ (e.g. recent, unintentional weight loss may require further investigation). For patients with high BMI, identify if they have conditions and/or risk factors that would make weight loss desirable (e.g. DM, osteoarthritis). For patients with low BMI or who are pre-frail/frail, muscle strengthening activities and multi-component physical activity that emphasises strength and functional balance should be recommended4​ to reduce sarcopenia as well as risk of falls and fractures.

Figure 1: BMI control management framework for 18 to 65 year olds.

BMI Control Management Framework.png Physical Activity Recommendation Process (PARP) Workflow ​​

Full list of subsidised weight management programmes offered under Healthier SG: Green Segment​, Orange Segment, Red Segment​.

 

“Green" segment

As patients in this group do not have significant risk factors, you may encourage them to sign up for programmes via HPB's Healthy 365 (H365) application​ , including those from the Health Promotion Board (HPB), SportSG, and People's Association (PA). Click here​ for the list of available "green" segment programmes. Self-administered assessment may be performed with the recommended tools such as the Physical Activity Readiness Questionnaire (PAR-Q) or the Get Active Questionnaire (GAQ). 

Indicators of physical activity (e.g. step count, moderate to vigorous physical activity [MVPA] minutes), patient's diet logging, and participation in national programmes administered by HPB, will be captured on the patient's H365 app.

“Orange" segment

As patients in this group have risk factors that may predispose them to cardiovascular events during physical activity, exercise pre-participation assessment by their enrolled doctor is recommended. Refer to the Physical Activity Recommendation Process (PARP)  workflow. 

Given the need for patient education on exercise, diet, and other lifestyle changes for chronic disease management, GPs may consider referring their patients to structured weight management programmes​. Patients with well-controlled chronic diseases can be referred to Active Health Targeted Programmes managed by SportSG and run by accredited Exercise is Medicine trained coaches.  Click here​ for the list of available "orange" segment programmes. GPs are encouraged to complete a referral form​. Patients should book and attend the recommended programmes so that the Active Health Coach can tailor and directly proceed with the exercise recommendation with them.  More details on SportSG’s referral workflow are available here .

For patients with poorly-controlled chronic diseases, the focus of treatment should be the proper management of their chronic diseases. GPs should work with other members of their care teams to achieve this. GPs may wish to contact their PCN HQs for support from care teams who can counsel patients on diet, exercise and other lifestyle modifications which can contribute to both improved chronic disease management and weight management. Patients with poorly controlled chronic diseases should also be monitored more closely by the care team to ensure the safety and adherence to the management regime. Where clinically relevant and beyond the capabilities of the PCN, GPs and/or their PCN teams may seek support for their patients from other available sources (e.g. community/primary care resources, cluster support) for the management of poorly controlled chronic conditions or weight-related issues. 


“Red" segment 

As patients in this group have significant risk factors that predispose them to cardiovascular events during physical activity, an exercise pre-participation assessment by a doctor is recommended. Refer to the Physical Activity Recommendation Process (PARP)  workflow. 

Given the need for patients to be educated and supported on the interactions between exercise and change in diet on underlying chronic diseases, GPs may consider referring patients to specialists or to tertiary-based weight management programmes.  In general, listed weight management programmes for the “red” segment will accept patients who meet the following criteria:

  1. Age:
    •  18 to 65 years

  2. BMI/health status:
    •  BMI 32.5 to 37.5 (for patients with comorbidities) and
    •  BMI ≥37.5 (for patients with or without comorbidities)

Details on the “red" segment programmes can be found here. Some programmes   may also accept patients outside of the stated criteria (e.g., those with BMI ≤32.5, or over the age of 65).

Once patients transit out of tertiary-based weight management programmes, GPs should consider referring them to community based structured weight management programmes and/or lifestyle counselling. De-escalation of programmes should be carried out in tandem with patients' progress in their weight change and chronic conditions they may have.​


Medication​1​

​
Medications should not be prescribed for cosmetic reasons and should be used as an adjunct to lifestyle modification.  Consider referring to a specialist for shared care if medications are indicated.  Medications licensed for obesity in Singapore include Phentermine, Orlistat, Liraglutide, and Contrave.

​Indications for prescribing medications for obesity:

  • BMI ≥30 kg/m2 with or without obesity-related complications or risk factors, OR 
  • When BMI is 27.5 – 29.9 kg/m2 among Asians with co-morbidities or complications of obesity such as hypertension, or DM.​


Surgery1​

Indications for offering bariatric surgery:

Clinically severe obesity

  • For Asians, BMI ≥37.5 kg/m2 OR BMI ≥32.5 kg/m2 with conditions like Type 2 DM, hypertension, lipid disorder, fatty liver, polycystic ovarian syndrome, obstructive sleep apnoea, and metabolic syndrome.

Consider referring to specialists or to tertiary-based obesity/weight management programmes if surgery is considered. Depending on the procedure, the mean weight loss after 10 years ranged from 14 to 25%.​​5​

The following data fields should also be documented in GPs' case notes as part of good clinical practice for all patients enrolled to their practice.

Submission of data fields marked with asterisks* are required for Healthier SG Annual Service Fee payments.​

  1. Weight*

  2. Height*

  3. BMI (in kg/m2; auto-calculated based on data input)

  4. Waist Circumference (in cm)

  5. Date


  1. HPB & MOH. HPB-MOH Clinical Practice Guidelines 1/2016: Obesity [Internet]. 2016 [cited 2022 August 17]. 

  2. Health Promotion Board. Metabolic Syndrome. 2022 [cited 2022 Dec 20]. ​​

  3. Harris TB. Weight and Body Mass Index in Old Age: Do They Still Matter? J Am Geriatr Soc. 2017 Sep;65(9):1898-1899. doi: 10.1111/jgs.14952. Epub 2017 Jul 17. PMID: 28714125; PMCID: PMC5704942. [cited 2022 November 23]

  4. SportSG & HPB. Singapore Physical Activity Guidelines (SPAG) [Internet]. 2022 [cited 2022 November 23]​​​​

  5. Sjostrom L, Lindroos AK, Peltonen M, Torgerson J, Bouchard C, Carlssom B et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med. 2004; 351(26):2683-2693. Doi: 10.1056/NEJMoa035622. [cited 2023 May 23]​