Preventing Obesity, Diabetes and

Cardiovascular Diseases through

Nutrition

GEH 1015/1049: Public Health in Action

Mary Chong
Associate Professor
Saw Swee Hock School of Public Health
National University of Singapore

Feb 2023
1
 Outline
▪ The contributions of obesity, diabetes and cardiovascular
diseases (CVD) to global health and health in Singapore

▪ Principles of healthy eating for prevention of non-

communicable diseases (NCDs)
▪ Busting diet myths

▪ Socio-ecological approach to dietary intervention

▪ Examples of population dietary interventions for NCDs prevention

2
 Part I:
The contributions of obesity, diabetes and cardiovascular
diseases (CVD) to global health and health in Singapore

3
Obesity: Global Phenomenon

4
5
6
 Co-morbidities in obese children

Strong predictor of adult obesity

& risk of chronic diseases

• Health issues
• Behavioral &
Emotional Difficulties
• Reduced educational
attainment

Stigmatization &
poor socialization
Low esteem

7
https://thecaribbeancurrent.com/obesity-in-children-and-teens/
UNICEF, 2017
8
Ethnic Indians and Malays will bear a disproportionate burden compared
with the Chinese majority.
Projections of global diabetes prevalence in 2035

10
 Body Mass Index

http://www.hpb.gov.sg/HOPPortal/health-article/HPB-039406
• Does BMI alone give you an accurate indication of
health, body fatness and fitness?
Risk of diabetes according to BMI (kg/m2) in the
Singapore Chinese Health Study

Body Mass Index (kg/m2)

12
Odegaard et al. Diabetes Care 2009
 Lowest insulin
sensitivity

Health Promotion Board

Age-adjusted fitted regression plots of ISI (mg/kg/min per μU/mL) against BMI (kg/m2) (A) and ISI
(mg/kg/min per μU/mL) against %body fat (B) for Chinese (Ο), Malay (∆), and South Asian (□)
subjects. Chin Meng Khoo et al. Diabetes 2014;63:1093-1102
 Diabetes is a life-long condition
associated with serious complications

Source: prudentialprimeproperties.net

https://www.diabetes.org.uk/Guide-to-diabetes/What-is-diabetes/
Singapore Burden of Disease Study 2019
Disability adjusted life years lost due to different health conditions

Non-communicable
diseases (NCDs)

15
Total of 1,047,768 life-years lost due to mortality and ill-health in 2019
What are the modifiable risk factors for
NCDs ?
 Part II:
What aspects of diet should we be concerned
to prevent non-communicable diseases
(NCDs)?

17
 EXCESS SPH2104
calories Public Health Nutrition

High sodium,
Saturated fats
preservatives

• Processed
food
Diet • High intake of
red meat
• High level of
• Fast food
seasonings

• Inadequate fruits Lack of fibre,

Poor quality
and vegetables vitamins and
carbohydrates
• Lack of whole- minerals
grains
• Refined CHO
• Micronutrient
• Sugar-sweetened
inadequacies
beverages
Carbohydrate: Quality
versus Quantity?
Minimally processed whole grains,
fruits, vegetables and beans

• Provide energy to support body

functions and physical activity
• Rich in vitamins, minerals and
phyto-nutrients
• High in fibre

=> Maintains blood sugar at steady

state (lower GI)
=> Promote good health – prevents
heart diseases and cancers

20
 Highly processed or Influence by
✓ Fat and fibre
refined carbohydrates content
✓ Addition of protein
✓ Processing
✓ Cooking method
✓ Ripeness
✓ Variety

• High in fat and nutrient-poor

• Definition of Glycaemic Index 21
 Why wholegrains ?

Fibre, B vitamins, minerals and

phytochemicals

22
23
 Should I avoid white rice ?
• Option 1: Mixing brown rice varieties with white rice
Rice variety Fibre Iron Zinc
White rice 1/5 ½ -
Brown rice Reference Reference Reference

Red rice Equal X2 x6

Black rice X3 - -
Purple rice Equal X2 X4
Wild rice Equal - x2
24
HPB website, Brown rice paradise
 Should I avoid white rice ?
Option 2: Choose varieties of rice with lower GI
Food GI
White rice, boiled (Italy) 102
White rice, boiled (India) 68
Brown rice (Canada) 66
Brown rice (Tai Ken, Taiwan) 82
Long grain, white, boiled (Australia) 50
Basmati, white, boiled (Australia) 83
Glutinous rice (Thailand) 94
Rice vermicelli (HK) 55

Adapted from B. Kaur et al, GI of rice and rice products, 2015 25

GI > 70 = High ; GI < 55= Low
 BREAKFAST
Option 3: Oats porridge OR
Assorted whole grain breads OR
Whole grain cereals with milk or yoghurt

LUNCH
Mixed whole grain noodles with white noodles
for extra ‘nutty’ flavor

SNACK
Ha lf and half muffins OR biscuits OR
pancakes
(mix of whole wheat flour and white flour)

DINNER
Adding oats or brown rice to white rice OR
Choice of brown, red, black or wild rice 26
 NOT an Option:
Eat in moderation by
regulating portion size consumed!

27
How much sugar are you drinking?
Sugar sweetened beverages SSBs

https://itunes.apple.com/sg/app/sugar-alert!/id600177995?mt=8;
Source: SPH NUS website Sugar App 28
National Nutrition Survey 2010

29
 with sugar-sweetened
beverages

• Hidden source of calories because people

associate drinks with thirst, not hunger
• Liquid calories are not filling and people do
not reduce their food intake at subsequent
meals following ingestion of liquid calories
-> high intake interfere with energy balance,
facilitating chronic overconsumption and weight gain
• Sugar is addictive! 30
 Fruit Juices – good or bad ?
Benefits
• Look cool and trendy!
• Consume recommended
servings of fruits and veg all in
one go !
• Provides vitamins, minerals,
phytochemicals like eating
whole fruits and vegetables
• Good for those who really
don’t like F&V
• Use up about-to-spoil produce
Caution
• Concentrated source of
calories (4 oranges in 250 ml)
• High sugar content (even if
natural sugars)
-> Extra calories
• Lack of fibre – affects satiety,
regulation of blood sugar
• Make only as much as you can
drink at one time
31
PROTEIN-RICH FOODS

3 servings a day,

of which 1 serving
from dairy or
calcium- fortified
products
Protein: cooking method matters

33
 Are high protein diets
the way forward for weight loss?

High-carbohydrates, low-fat diets versus

High-protein, low-carbohydrate diets
34
 High protein diets for
extended time may…
• Result in nutritional deficiencies or insufficient fibre
-> bad breath, headache and constipation
• Worsen kidney function in those with kidney disease
• Include ++ red meat, full-fat dairy products -> increase risk of
heart disease
• Some studies show that high protein diets, in particular from
animal sources are associated with risk of Type 2 diabetes
• Not cheap!
• Not for everyone, esp. those exercising and regular sports

35
 37
https://www.pinterest.com/ax3/vitamins/
• Required as functional
parts of enzymes involved
in energy release and
storage –
“converts food to energy”

• Referred to as co-enzymes
and cofactors to catalyze
specific reactions

• Essential in catabolic
pathways and anabolic
pathways
Types Food groups
Lacto-vegetarian exclude meat, fish, poultry and eggs; include dairy products
Inadequate
fruits and
Ovo-vegetarian exclude meat, poultry, seafood and dairy products, but allow eggs.
vegetables

Lacto-ovo vegetarian exclude meat, fish and poultry, but allow dairy products and eggs.

Pescatarian exclude meat and poultry, dairy, and eggs, but allow fish.
Pollotarian exclude meat, dairy and fish, but allow poultry.
Vegan exclude meat, poultry, fish, eggs and dairy products
Flexitarian/Semi- primarily a plant-based diet but includes meat, dairy, eggs, poultry
vegetarian and fish on occasion or in small quantities.
Deficiencies
Protein,
Omega-3 fatty acids, Inappropriate
Calcium , Vitamin D, vegetarian
Vitamin B12, Iron and diets
zinc
 Part III:

Preventive dietary interventions to reduce

the risk of NCDs

40
 Ecological model for the development of obesity
proposed by Egger and Swinburn (BMJ 1997)

Obesity as a 'normal' response to an abnormal

environment rather than a 'pathology' of individuals
41
Socio-ecological model

Story et al 2008, Ann Rev of Pub Health, 29, 253-272, Glanz et al, Am J of Health Promot 2005 ; 19 (5):330-333
 Social influences – role modeling
• Children show a tendency to taste
unfamiliar foods more readily when they
observe adults eating them when the food
is merely offered to the child.

• Children model themselves on their

parents’ behavior, lifestyle and body
dissatisfaction.

• Peer modelling: watching a peer eat a food

one disliked promoted willingness to
choose and eat that food subsequently.
LV Harper and KM Sanders, 1975; LL Birch, 1980
Places and settings for healthy eating and
(Physical environment)
• Multiple settings where people eat, procure food
such as home, work sites, childcare, schools,
restaurants, food courts, supermarkets and grocery
stores

• Accessible and Affordable healthy food choices and

physical activities

• What programs are in schools, childcare and work

places to encourage health eating?
 Advertising/Media Policies

NBC, 2007
Healthier Dining Programme

Healthier Ingredient Scheme

46
 For effective interventions…
• Go beyond the health sector
• ‘Whole- of- Government’ and ‘Whole-of-society’
approach

• Multi-sectoral approach is required to create enabling

environments, so that healthy choices are easy choices
Trends in Endocrinology and Metabolism
48
 Key Takeaways

• Among modifiable causes of disease, diet-related factors are a

major contributor to global ill-health

• Different dietary components work in synergy to prevent non-

communicable diseases.

• Knowledge alone is not sufficient; Environmental and policy

interventions may be among the most effective strategies for
creating population-wide improvements in eating.

49