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ORIGINAL ARTICLE
Longitudinal study of the socio-demographic
determinants of changes in body weight and waist
circumference in a multi-ethnic Asian population
SK Ong1, CW Fong1, S Ma1, J Lee2, D Heng1, M Deurenberg-Yap3,4, Y-L Low5, M Tan6, W-Y Lim1
and ES Tai6
1
Epidemiology and Disease Control Division, Ministry of Health, Singapore, Singapore; 2Department of Epidemiology
and Public Health, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore; 3Health
Services Research and Evaluation Division, Ministry of Health Singapore, Singapore, Singapore; 4Duke-Graduate Medical
School, National University of Singapore, Singapore; 5Brenner Centre for Molecular Medicine, Singapore Institute for Clinical
Sciences (SICS), Singapore, Singapore and 6Department of Endocrinology, Singapore Health Services, Singapore, Singapore
Objective: To examine the changes in weight and waist circumference of adult Singaporeans between 1998 and 20052007,
and the associations of these changes with demographic and socio-economic factors.
Methodology: A prospective study, which followed up participants aged 1869 years from the 1998 National Health Survey.
Analysis was performed on data from 2483 individuals (53% of original sample) who returned for follow-up in 20052007. Body
weight and waist circumference were measured both at baseline and follow-up. Logistic regression was used to examine factors
associated with being overweight and obese at baseline. Linear regression was used to examine changes in weight and waist
circumference over time. The variables examined were age, gender, ethnicity, marital status, educational level, housing and
employment status, smoking, alcohol consumption and sports activities.
Results: Mean weight for the population increased over the follow-up period by 1.48 kg (s.d. 4.95) and mean waist
circumference increased by 3.32 cm (s.d. 7.92). Cross-sectionally, those who were overweight or obese were more likely to be
Malays or Indians, married, homemakers and have lower educational level. Prospectively, individuals who gained the most
weight were younger, more likely to be ethnic minority groups and have the lowest body mass index (BMI) at baseline. They
also appeared to be of higher socio-economic status (SES) based on housing type. These associations were statistically significant
even after adjusting for other variables.
Conclusion: Obesity prevention should start early in the younger age. Preventive programs need to reach out to Malay and
Indian ethnic groups and those with higher SES. These findings should be used in designing messaging of preventive strategies.
International Journal of Obesity (2009) 33, 12991308; doi:10.1038/ijo.2009.173; published online 8 September 2009
Keywords: longitudinal; Asian ethnic groups; weight gain; waist circumference; socio-demographic factors
Introduction
The prevalence of overweight and obesity has risen significantly over the past few decades in both developed and
developing countries worldwide, reaching epidemic proportions in many countries.14 In Singapore, cross-sectional
community-based National Health Surveys (NHS) have
found rising trends in obesity and overweight prevalence.
Correspondence: Dr ES Tai, Department of Endocrinology, Singapore General
Hospital, Outram Road, Block 6 level 6, Room B35, Singapore 169608,
Singapore.
E-mail: eshyong@pacific.net.sg
Received 28 April 2009; revised 14 July 2009; accepted 26 July 2009;
published online 8 September 2009
1300
neoplastic disease.7 Although the majority of these studies
involved participants in Europe, the USA, Israel and
Australia, large studies from China8 and Korea9 suggest that
the impact of obesity on mortality is similar in populations
of Asian ancestry. Many studies have also documented the
association of obesity with the occurrence of many high
burden chronic diseases.1013
Despite the large number of studies documenting the
negative impact of obesity on morbidity and mortality, few
studies have included repeated measurements of obesity,
which would help to determine whether there are critical
periods in life when individuals become overweight or
obese, and also whether it is possible to identify factors that
would predict weight gain before it occurs. Such studies
would help policy makers develop appropriate preventive
strategies that target the population at greatest risk, at a
time when the risk of weight gain is the greatest. Various
studies have shown that weight gain is a function of baseline
age and BMI, as well as other lifestyle and demographic
factors including dietary intake, physical activity, socioeconomic differences, and to a lesser extent ethnicity and
gender.1417 To our knowledge, few (if any) studies of this
nature have been conducted in Asian populations. Although
the effects of obesity on mortality and chronic disease seem
similar between populations, it is conceivable that the
patterns of weight gain and the factors that predict weight
gain may differ because of differences in patterns of dietary
intake and physical activity between populations or ethnic
groups. It is also possible that different populations may
have different susceptibility to weight gain in an environment of nutrient excess. In addition to weight gain,
increased abdominal fat or waist circumference has been
found to be strongly associated with metabolic and cardiovascular diseases.18 Those with a normal BMI, but large waist
circumference, are also found to have higher mortality
risk.19,20 The aim of this study is to examine the function
of age, baseline BMI and socio-demographic factors in
predicting changes in weight and waist circumference in a
multi-ethnic Asian population living in Singapore.
Measurements
Body weight (to the nearest 0.01 kg) was obtained with
participants dressed in light clothing using electronic
weighing scales; height (to the nearest 0.1 cm) was measured
using wall-mounted stadiometer for all the participants
without shoes. Waist circumference (to the nearest 0.1 cm)
was measured at the midpoint between the lower rib margin
and the iliac crest using measuring tape. Participants were
instructed to remove any objects such as keys and mobile
phone before measurement.
The baseline socio-demographic variables included in this
study were gender, ethnic groups, marital status, age, highest
educational level, housing type, employment status and BMI
categories. Highest educational level, housing type and
employment status were used as proxy measures for socioeconomic status (SES). The highest educational level attained
was defined as (i) no formal education received o6 years of
education, (ii) primary education received 67 years
of education, (iii) secondary education received 710 years
of education, (iv) pre-university/diploma received 1113
years of education and (v) degree/professional qualification received X14 years of education. Housing type was
classified as (i) public apartment with 13 room, (ii) public
apartment with four rooms and higher, (iii) private apartment including condominium and (iv) private landed
property. Public apartment refers to subsidized apartment
built by the government. Private apartment refers to apartment or condominium built by private property developers.
A total of 85% of Singapore residents live in public
apartments, 10% in private apartments and 5% in private
landed properties.24 In general, the cost of housing increases
from public apartment to private apartment and landed
property. As 85% of the population lives in public housing,
this variable may not have the same interpretation as in
1301
other populations. Therefore, the type/size of public apartments, which are associated with cost, is highly relevant
in this context. For employment status, participants were
also grouped into five categories (working, non-working,
homemaker, students and unemployed).
BMI categories were defined based on WHO classification25 of BMI for adultsFunderweight: BMI o18.5 kg m2;
normal weight: BMI 18.5 to o24.9 kg m2; pre-obese or overweight: BMI 25.0 to 29.9 kg m2 and obese: BMI 30.0 kg m2
or more.
Lifestyle factors included in the analyses were baseline
sports activity, smoking and alcohol consumption. Sports
activity was based on the frequency of participation in sports
for at least 20 min per occasion with three categories: regular
exercise (3 days a week), occasional exercise (p3 days a week)
and no exercise (no participation in any form of sports that
lasted for at least 20 min per occasion).26 Smoking status was
obtained using a questionnaire based on the WHO classification criteria for smoking: non-smoker (never smoked before
or smoked too little in the past to be regarded as an exsmoker), ex-smoker (formerly a daily smoker, but currently
does not smoke at all), occasional smoker (smokes cigarettes,
but not everyday) and daily smoker (smokes cigarettes
at least once a day including those who smoke every day,
but have to stop temporarily because of religious fasting
or medical records).27 Alcohol consumption was classified
according to the frequency of alcohol intake: regular drinker
(drinks 44 days a week), frequent drinker (drinks 13 days a
week), occasional drinker (drinks o3 days a month) and
non-drinkers are those who do not drink alcohol.
Data analysis
We carried out linear regression analysis for the change
in weight and waist circumference for all participants.
Change in weight and waist circumference is the difference
between the measurements at baseline and follow-up. The
two measurements were correlated (r 0.526, Po0.001).
The weight, waist circumference and BMI of the cohort were
normally distributed.
We used Students t-test and test of binomial proportions
to examine baseline differences between individuals who
returned for follow-up and were included in the analyses
(respondents) and those who did not (non-respondents).
We examined the association between the risk of being
overweight (BMIX25.0 kg m2) or obese (BMIX30 kg m2)
and the baseline characteristics including age, gender, ethnic
groups, marital status, educational level, housing type and
employment status, using univariate and multiple logistic
regression adjusting for baseline smoking, alcohol consumption and sports activity status.
In the prospective analysis, changes in weight and waist
circumference were calculated by subtracting weight at baseline from weight at follow-up. Repeated measures analysis of
variance were used to examine whether the changes were
different among the categories of variable. We used linear
Results
Table 1 presents the baseline characteristics of participants
who did (n 2483) and did not (n 2240) return for followup. Those who returned for follow-up were more likely to
be of Chinese ethnicity, be married and working. More
individuals aged 4049 years returned for follow-up than
those aged 1829 years. In addition, they were more likely to
be non-smokers, to have a BMI in the normal range and have
a higher level of education.
The mean duration of follow-up was 7.68 years
(s.d. 0.92). The mean weight and waist circumferences
at baseline were 62.02 kg (s.d. 12.43) and 79.81 cm (s.d.
11.23), respectively. Over the follow-up period, mean weight
increased by 1.48 kg (s.d. 4.95), mean waist circumference
increased by 3.32 cm (s.d. 7.92) and mean BMI increased by
0.18 kg m2 (s.d. 1.84). A total of 73.9% (n 1832) of the
participants had weight change ranging from 5 to 5 kg;
1534 participants (61.9%) had gained weight, whereas
916 participants (36.9%) lost weight. The majority (78.3%,
n 1944) of the participants remained in their baseline BMI
categories. A total of 10.6% (n 159) of participants with
normal baseline BMI (18.524.9 kg m2) became overweight
at follow-up, and 9.4% (n 56) of those with baseline BMI
25.029.9 kg m2 were obese at follow-up (data not shown).
Cross-sectional analyses of baseline factors revealed that
age, marital status, educational level, housing types and
employment status were significantly associated with an
increased risk of being overweight or obese (Table 2). Both
overweight and obesity were associated with age and the risk
increased in a monotonic manner except in the oldest age
group (age 6069) in which the risk declined. Being married,
separated or divorced and from lower educational level were
also associated with increased risk of overweight and obesity.
As discussed in a preceding section, there was a statistically
significant interaction between ethnicity and gender in
International Journal of Obesity
1302
Table 1
Non-respondents
(n 2240) %
Gender
Male
Female
46.4
53.6
45.9
54.1
Ethnic group
Chinese
Malay
Indian
70.2
16.1
13.7
66.3
20.0
13.6
Age (year)
1829
3039
4049
5059
6069
20.7
33.1
29.4
11.0
5.8
30.9
30.6
19.3
10.1
9.1
Marital status
Single
Married
Divorced/widowed/separated
22.8
74.8
2.3
32.1
65.1
2.9
11.5
24.1
33.6
17.2
13.6
17.0
21.3
29.6
17.5
14.6
22.4
61.4
23.8
61.2
7.5
8.7
6.5
8.4
Employment status
Working
Homemaker
Student
Retired
Unemployed
71.1
17.3
5.8
2.8
2.9
66.0
18.9
6.9
2.9
5.3
Smoking status
Non-smoker
Daily smoker
Ex-smoker
Occasional smoker
79.6
13.0
5.4
2.0
76.3
16.7
4.9
2.2
Alcohol consumption
Non-drinker
Occasional drinker
Frequent drinker
Regular drinker
62.1
30.2
5.2
2.5
64.2
28.3
5.7
1.9
Sports activity
No exercise
Occasional exercise
Regular exercise
56.9
26.9
16.2
56.5
27.1
16.4
8.3
60.5
24.0
7.2
9.9
56.3
26.3
7.5
Baseline characteristic
Education level
No formal education
Primary
Secondary
Pre-university/diploma
Degree/professional
qualification
Housing type
Public apartment 13 rooms
Public apartment 4 rooms
and above
Private apartment
Landed property
P-value
0.753
0.002
o0.001
o0.001
o0.001
0.424
o0.001
0.004
0.220
0.960
0.024
1303
Table 2
Baseline characteristic
Overweight
Multivariate a
Age-adjusted
OR
Obesity
95% CI
OR
95% CI
Multivariate a
Age-adjusted
OR
95% CI
OR
95%CI
Age (year)
1829
3039
4049
5059
6069
1.00
2.69
3.45
3.69
3.18
(1.96,
(2.51,
(2.52,
(2.02,
3.68)
4.74)
5.40)
5.02)
1.00
1.44
1.63
1.72
1.30
(0.98,
(1.09,
(1.07,
(0.70,
2.13)
2.43)
2.77)
2.42)
1.00
1.86
2.63
3.32
1.53
(1.09,
(1.56,
(1.84,
(0.66,
3.18)
4.44)
5.99)
3.57)
1.00
0.86
1.05
1.32
0.57
(0.45,
(0.55,
(0.62,
(0.20,
1.63)
2.01)
2.80)
1.63)
Ethnicity/gender
Chinese man
Chinese woman
Malay man
Malay woman
Indian man
Indian woman
1.00
0.58
2.00
2.22
1.49
2.65
(0.46,
(1.41,
(1.54,
(1.02,
(1.84,
0.74)
2.83)
3.20)
2.17)
3.82)
1.00
0.46
1.69
1.59
1.42
1.87
(0.35,
(1.15,
(1.03,
(0.96,
(1.23,
0.62)
2.48)
2.45)
2.09)
2.85)
1.00
0.63
2.78
7.25
2.35
4.34
(0.38, 1.06)
(1.59, 4.86)
(4.54, 11.57)
(1.28, 4.32)
(2.58, 7.30)
1.00
0.45
2.21
4.27
2.28
2.57
(0.25,
(1.19,
(2.33,
(1.22,
(1.38,
0.81)
4.10)
7.84)
4.26)
4.80)
Marital status
Single
Married
Divorced/widowed/separated
1.00
2.45
3.02
(1.80, 3.33)
(1.56, 5.83)
1.00
1.45
1.82
(1.02, 2.06)
(0.90, 3.68)
1.00
2.61
3.65
(1.49, 4.57)
(1.35, 9.84)
1.00
1.42
1.25
(0.75, 2.69)
(0.42, 3.71)
Education
No formal education
Primary
Secondary
Pre-university/diploma
Degree/professional qualification
1.00
1.24
0.90
0.58
0.70
(0.89,
(0.64,
(0.39,
(0.47,
1.72)
1.24)
0.86)
1.04)
1.00
0.98
0.81
0.59
0.61
(0.69, 1.39)
(0.5, 1.16)
(0.38, 0.90)
(0.38, 0.95)
1.00
0.81
0.55
0.20
0.33
(0.52, 1.26)
(0.34, 0.88)
(0.10, 0.41)
0.17, 0.63)
1.00
0.70
0.60
0.30
0.43
(0.43,
(0.36,
(0.14,
(0.20,
Housing type
Public apartment 13 rooms
Public apartment 4 rooms and above
Private apartment
Landed property
1.00
0.97
0.73
0.67
(0.76, 1.22)
(0.48, 1.09)
(0.46, 1.00)
1.00
1.09
1.19
1.19
(0.85, 1.40)
(0.76, 1.87)
(0.77, 1.83)
1.00
0.61
0.32
0.42
(0.44, 0.86)
(0.14, 0.71)
(0.22, 0.81)
1.00
0.78
0.89
1.01
(0.54, 1.12)
(0.37, 2.14)
(0.49, 2.08)
Employment status
Working
Homemaker
Student
Retired
Unemployed
1.00
1.33
0.23
0.63
0.78
(1.04, 1.69)
(0.11, 0.51 )
(0.35, 1.12)
(0.42, 1.45)
1.00
1.31
0.29
0.94
0.82
(0.96,
(0.13,
(0.49,
(0.43,
1.00
2.15
0.29
0.28
0.72
(1.53,
(0.07,
(0.07,
(0.22,
1.00
1.50
0.28
0.49
0.79
(0.95,
(0.06,
(0.10,
(0.23,
1.78)
0.69)
1.83)
1.60)
3.02)
1.24)
1.21)
2.33)
1.14)
1.02)
0.66)
0.93)
2.36)
1.31)
2.26)
2.69)
Abbreviations: OR, odds ratio; CI, confidence interval. aAdjusted for age, gender, ethnicity, marital status, educational level, housing type, employment status and
baseline smoking, alcohol consumption and sports activity status. For age adjustment analyses, the results for the age categories were not adjusted for age. Bold:
statistically significant with P-value o0.05, 95% CI does not include 1.
Discussion
This study has allowed us to correlate the risk of overweight/
obesity and weight gain with socio-demographic factors in
a multi-ethnic Asian population, both cross-sectionally
and prospectively. Cross-sectional analyses revealed that
the prevalence of overweight and obesity increase with age
and are most prevalent among the middle aged individuals
(5059 years). By using a prospective study design, we have
1304
Table 3
Means of weight and waist circumference at baseline and the changes by baseline characteristics
Baseline characteristics
Change a
1.48 (4.95)
Baseline
Change a
79.81 (11.23)
3.32 (7.92)
All
62.02 (12.43)
Age (years)
1829
3039
4049
5059
6069
59.18
62.01
63.46
64.09
60.91
(12.88)
(12.65)
(12.07)
(12.28)
(9.44)
3.58
1.91
0.73
0.42
1.01
(5.80)
(4.50)
(4.52)
(4.33)
(3.94)
73.76
79.07
82.01
84.86
84.87
(10.01)
(10.95)
(10.80)
(10.99)
(9.13)
4.90
3.39
3.15
1.68
1.11
(6.92)
(9.89)
(5.80)
(7.55)
(7.48)
Ethnicity/gender
Chinese man
Chinese woman
Malay man
Malay woman
Indian man
Indian woman
67.11
54.46
69.81
62.55
70.58
62.58
(11.35)
(8.82)
(12.32)
(12.38)
(11.41)
(12.44)
1.54
0.78
2.69
2.56
1.87
2.11
(4.90)
(4.05)
(5.90)
(5.75)
(5.36)
(6.32)
83.98
72.96
86.28
79.55
89.23
82.34
(9.77)
(8.26)
(10.38)
(12.51)
(10.03)
(11.1)
2.70
2.87
4.92
5.25
3.61
4.27
(8.15)
(6.28)
(9.50)
(9.69)
(10.45)
(7.32)
Marital status
Single
Married
Divorced/widowed/separated
58.55 (12.5)
63.08 (12.28)
61.85 (10.53)
Education level
No formal education
Primary
Secondary
Pre-university/diploma
Degree/professional qualification
62.03
63.59
61.25
60.93
62.52
(11.49)
(12.29)
(13.08)
(11.97)
(12.15)
0.10
1.00
2.04
1.88
1.82
Housing typeb,c
Public apartment 13 rooms
Public apartment 4 rooms and above
Private apartment
Landed property
62.18
62.10
60.84
62.08
(12.65)
(12.29)
(13.00)
(12.41)
Employment status
Working
Homemaker
Student
Retired
Unemployed
63.05
59.61
57.11
61.14
61.80
Smoking Status
Non-smoker
Daily smoker
Ex-smoker
Occasional
73.91 (10.08)
81.53 (10.98)
82.63 (10.39)
4.83 (6.37)
2.86 (8.35)
3.40 (5.56)
(4.88)
(5.10)
(5.10)
(4.54)
(4.54)
83.06
82.22
78.42
77.56
79.14
(10.35)
(10.95)
(11.72)
(10.70)
(10.57)
2.01
3.09
3.62
3.41
3.97
(7.86)
(7.05)
(8.40)
(6.40)
(9.69)
1.23
1.71
1.26
0.81
(5.51)
(4.85)
(3.96)
(4.82)
79.93
79.88
78.63
80.08
(11.09)
(11.36)
(11.01)
(10.94)
2.88
3.40
3.99
3.32
(7.42)
(8.10)
(9.84)
(5.84)
(12.49)
(11.45)
(13.05)
(10.62)
(12.85)
1.46
0.64
4.54
0.93
3.30
(4.71)
(4.67)
(6.45)
(4.07)
(6.42)
80.57
79.22
71.22
84.20
78.05
(11.37)
(10.09)
(9.24)
(10.04)
(11.23)
3.13
3.39
5.51
0.21
6.08
(8.11)
(5.81)
(6.83)
(8.65)
(12.65)
60.71
66.50
69.91
63.84
(11.87)
(13.05)
(13.67)
(12.15)
1.44
1.94
0.67
2.47
(4.87)
(5.52)
(4.19)
(5.79)
78.58
83.94
88.00
80.32
(10.89)
(10.97)
(11.37)
(10.92)
3.39
3.35
1.70
4.59
(7.65)
(10.14)
(5.93)
(6.25)
Alcohol consumptionc
Non-drinker
Occasional
Frequent
Regular drinker
61.29
63.00
63.74
64.78
(12.40)
(12.57)
(11.61)
(11.88)
1.55
1.45
0.93
1.54
(5.10)
(4.90)
(3.81)
(4.17)
79.41
80.13
81.37
82.83
(11.21)
(11.48)
(10.07)
(10.62)
3.53
2.91
3.49
2.80
(7.68)
(7.58)
(11.93)
(7.44)
61.21 (12.44)
63.07 (13.07)
63.13 (11.08)
1.31 (4.91)
2.05 (4.73)
1.18 (5.41)
79.68 (11.43)
79.77 (11.58)
80.33 (9.91)
3.17 (8.55)
3.51 (6.77)
3.57 (7.43)
46.45
57.84
70.98
84.87
2.85
1.63
1.06
0.15
65.59
76.16
88.18
98.76
4.53
3.39
3.07
2.17
(5.08)
(7.96)
(8.06)
(12.22)
3.18 (5.92)
1.01 (4.52)
0.18 (4.33)
(4.14)
(4.55)
(5.48)
(6.52)
(4.97)
(7.91)
(7.05)
(9.77)
(6.78)
(8.05)
(7.93)
(7.90)
Abbrerviation: SD, standard deviation. aChange in weight and waist circumference is the difference between the measurements at baseline and follow-up. bChanges
in weight were NOT statistically significant different among the categories, with P-value 40.05 using repeated measures of ANOVA. cChanges in waist were NOT
statistically significant different among the categories, with P-value 40.05 using repeated measures of ANOVA.
1305
Table 4
Effects of baseline variables on change in weight and waist circumference by linear regression
Baseline characteristic
Age-adjusted
b
95% CI
Multivariate a
Age-adjusted
95% CI
Age (year)
1829
3039
4049
5059
6069
1.67
2.85
4.00
4.59
2.20,
3.39,
4.70,
5.47,
1.15
2.31
3.30
3.71
0.91
2.08
3.03
3.59
1.58,
2.79,
3.92,
4.80,
0.23
1.36
2.15
2.39
1.52
1.76
3.23
3.80
Ethnic/gender
Chinese man
Chinese woman
Malay man
Malay woman
Indian man
Indian woman
0.92
1.20
0.91
0.73
0.78
1.36,
0.46,
0.19,
0.08,
0.01,
0.47
1.94
1.63
1.52
1.54
0.97
1.34
1.51
1.01
1.34
1.49,
0.54,
0.66,
0.21,
0.49,
0.46
2.14
2.35
1.81
2.20
0.06
2.25
2.46
1.23
1.72
Marital status
Single
Married
Divorced/widowed/separated
0.52
0.42
1.05, 0.03
1.78, 0.95
0.60
0.56
1.22, 0.02
1.93, 0.81
0.78
0.44
95% CI
2.38,
2.65,
4.38,
5.26,
0.65
0.87
2.07
2.34
0.66
0.90
2.12
2.23
1.79,
2.09,
3.60,
4.24,
0.47
0.29
0.65
0.22
0.69, 0.79
1.03, 3.48
1.26, 3.66
0.1, 2.54
0.44, 2.99
0.24
2.77
2.91
1.44
1.92
1.10,
1.43,
1.50,
0.10,
0.49,
0.62
4.10
4.32
2.77
3.34
1.66, 0.12
1.83, 2.7
1.11
0.02
2.14, 0.08
2.33, 2.28
Education level
No formal education
Primary
Secondary
Pre-university/diploma
Degree/professional qualification
0.27
0.60
0.20
0.37
0.42,
0.09,
0.56,
0.42,
0.95
1.28
0.96
1.16
0.22
0.39
0.07
0.17
0.48,
0.32,
0.74,
0.71,
0.91
1.10
0.88
1.05
0.43
0.41
0.01
0.75
0.70,
0.72,
1.25,
0.55,
1.56
1.53
1.27
2.05
0.44
0.29
0.05
0.81
Housing type
Public apartment 13 rooms
Public apartment 4 rooms and above
Private apartment
Landed property
0.58
0.34
0.39
0.12, 1.04
0.45, 1.13
0.37, 1.15
0.68
0.95
0.61
0.21, 1.15
0.12, 1.78
0.19, 1.40
0.61
1.36
1.09
0.16, 1.37
0.05, 2.66
0.17, 2.34
0.92
2.06
1.46
Employment status
Working
Homemaker
Student
Retired
Unemployed
Smoking status
Non-smoker
Daily smoker
Ex-smoker
Occasional
Alcohol consumption
Non-drinker
Occasional
Frequent
Regular drinker
Physical activity status
Regular
Occasional
No exercise
BMI group (kg m2)
18.524.9
o18.5
25.029.9
X30.0
0.35
0.89
0.3
0.89
0.86,
0.01,
0.94,
0.25,
95% CI
0.71,
0.89,
1.30,
0.65,
1.60
1.47
1.40
2.27
0.13, 1.69
0.67, 3.44
0.13, 2.78
0.16
1.79
1.54
2.01
0.06
0.86
0.24
0.75
0.65,
0.11,
1.61,
0.39,
0.53
1.82
1.12
1.89
0.6
0.79
0.96
2.25
0.24, 1.44
0.69, 2.27
3.01, 1.09
0.4, 4.11
0.58
0.56
1.41
1.93
0.41,
1.06,
3.69,
0.02,
0.66
0.10
0.67
0.10, 1.22
0.76, 0.94
0.69, 2.02
0.28
0.33
0.42
0.35, 0.91
1.20, 0.55
0.93, 1.76
0.07
1.06
0.93
0.86, 1.00
2.45, 0.34
1.31, 3.15
0.02
1.10
0.67
1.07, 1.03
2.55, 0.36
1.57, 2.91
0.35
0.72
0.73
0.76, 0.07
1.57, 0.13
0.48, 1.94
0.17
0.86
0.50
0.62, 0.28
1.74, 0.02
0.73, 1.73
0.81
0.11
0.15
1.50, 0.12
1.52, 1.29
2.15, 1.85
0.21
0.34
0.33
0.96, 0.54
1.13, 1.80
1.73, 2.38
0.02
0.42
0.55, 0.51
0.03, 0.86
0.30
0.23
0.84, 0.24
0.23, 0.68
0.49
0.08
0.39, 1.36
0.65, 0.81
0.13
0.07
0.78, 1.03
0.82, 0.69
0.57
0.77
1.64
1.27, 0.14
1.53, 0.01
2.6, 0.68
0.75
1.37
2.57
1.45, 0.06
2.15, 0.59
3.57, 1.58
0.64
0.66
1.55
1.8, 0.53
1.93, 0.62
3.14, 0.06
0.90
1.34
2.78
2.07, 0.26
2.64, 0.03
4.44, 1.12
1.57
2.16
0.87
3.83
Abbreviation: CI, confidence interval. aAdjusted for age, gender, ethnic group, marital status, educational level, housing type, baseline BMI, smoking, alcohol
consumption and sports activity status. For age adjustment analyses, the results for the age categories were not adjusted for age. Bold: changes of weight and waist
circumference were found to be statistically significant with P-value o0.05 by linear regression.
1306
obesity should begin in early adulthood, before the development of obesity. This is particularly important as the
treatment of long-standing obesity after it has occurred is
often more difficult and the effect on cardiovascular risks
may not be reversible.36
Similar to an earlier study,28 we found that the effect of
gender on obesity is ethnic specific. Malays and Indians had
the highest levels of overweight and obesity at baseline, and
obesity was more pronounced in women from these ethnic
groups. During the period of follow-up, we found that Malay
men gained the most weight, whereas both Malay men and
Malay women exhibited the greatest increase in waist
circumference. In contrast, Chinese women had the lowest
levels of overweight and obesity at baseline and were the
least likely to gain weight or increase their waist circumference. Such ethnic differences in susceptibility to obesity
have been reported earlier.3739 However, the basis of these
ethnic differences is unclear. In some earlier studies, these
differences were attenuated when SES was taken into
account suggesting that these ethnic differences may be
related to differences in SES.37,40 In our study, ethnicity
remains a significant predictor of weight gain and obesity,
even after adjustment for educational level, housing type
and employment status.
Our finding on the association of marital status with
increased risk of being overweight is similar to earlier studies
in which it was found that the risk was attenuated by the
effect of ethnicity and gender.41,42 In our prospective
analyses, being married or having been married is associated
with weight loss during adulthood, but this association was
not statistically significant after adjusting for age and other
covariates. We believe that the effects associated with marital
status were confounded by age, as single individuals were
younger and younger age was associated with greater weight
gain.
The impact of SES on change in weight and waist
circumference in our study is noteworthy. First, in our study,
it appeared that higher SES (higher education level, larger/
more expensive homes) was associated with greater gain in
weight and waist circumference (although the association
with education level was no longer statistically significant
after adjustment for age and other risk factors). This is in
contrast to a study conducted in the United Kingdom
reported that lower SES was associated with greater weight
gain.15 We believe that this may be related to greater time
spent at work, which is often sedentary, among individuals
from higher SES, and hence less time to participate in leisure
time physical activity. Singapore is a small country, which
is completely urbanized and occupational physical activity
largely reflects that of a developed economy (that is,
low levels of occupational physical activity). In this environment, leisure time physical activity becomes a more important determinant of adult weight gain. Even though high
SES was associated with greater weight gain in adulthood,
low SES was associated with higher prevalence of obesity at
baseline. The reason for this apparent contradiction may
International Journal of Obesity
1307
as it is during this period that more weight gain was
observed. These data may assist in the identification of
opportunities to implement such preventive strategies. For
example, in Singapore, men undergo compulsory military
training with intermittent contact with the armed forces
until the age of 40. Given our findings, this would be an
opportune avenue through which the importance of a
healthy diet and regular physical activity could be communicated. In addition, preventive strategies should also reach
out to the ethnic minority groups and need to be culturally
sensitive and acceptable to ensure that all segments of the
population are reached. Although marital status and education level were not found to be significant predictors of
weight change in multivariate analysis, the knowledge that
individuals who were single had higher levels of education
and larger/more expensive homes tended to gain the most
weight would be useful for designing messaging of preventive strategies.
Conflict of interest
The authors declare no conflict of interest.
Acknowledgements
This study was funded by the Biomedical Research Council
of Singapore grant number 03/1/27/18/216. This study was
approved by the Singapore General Hospital Institutional
Review Board.
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