Fat Shaming Kids in Singapore

Preface: I myself think this is a bad idea. However, Singapore is one a very odd country and one of my favorites to read about. I thought I would write about this program.

In every developed country in the world, childhood obesity rates have been increasing. Kids are getting fatter! The singular exception to this trend is Singapore from 1992 to 2005. 

Source

How did they do this? They implemented the Trim and Fit (TAF) program, running from 1992 and 2007. 

The TAF Program

 Some Anecdotes: 

“The school had all of us in TAF skip recess-- the only 30-minute break time for meals-- and replace it with exercise. Now, it makes perfect sense to increase our activity level in the hope that our excess weight would be reduced. But you have no idea HOW it was carried out, in my school at least. First off, the area where all of us "TAF girls" had to exercise was right in front of the school canteen-- in front of hundreds of other school mates. What this meant is that we couldn't hide the shame of belonging to TAF. Everyone automatically knew. Even worse, we had to face the embarrassment of exercising in front of an audience of our "normal" peers.” - Tangram Blog

“Yeah I remember when everyone was sitting down during assembly they made a public announcement for all TAF club members to stand up and head to another part of the school. So everyone was looking at us and knew who was in TAF club. Honestly it felt quite humiliating... especially at that age. I never forgot the feeling. 

Also remember not being able to eat with my friends and classmates during recess because we had to exercise. And then we had no time to eat because recess was 30 mins, exercise was 15 mins and the queue to buy food was 5-10 mins.” - Top rated comment of reddit thread 

Overweight children(BMI greater than 25) were mandated to do aerobic workouts such as jogging or hiking. This took place either before school, after school, or during lunch breaks. 

Schools also used a variety of methods to help reduce the caloric intake of overweight students.

1. The schools issued "calorie cash" to limit the amount of calories overweight students could eat. The fatter you were the less calorie cash you got. 

2. The Calorie Cafe program restricted calorie intake to less than 350 calories during recess time.

Schools were tracked by scores on the annual fitness test(NAPFA). The Ministry of Education gave Gold and Silver awards to schools passing health standards. Additionally, individual students are given bronze, silver and gold awards based on performance. 

Why does it work? 

The TAF program works extremely well at reducing obesity compared to other school interventions. It achieved a 33% reduction in obesity over 10 years- a huge result. This meta analysis shows that “school-based obesity prevention intervention programs were significantly, but mildly effective (effect size = 0.076) in reducing BMI.” The key problem is that weight loss requires a lifestyle change that a school based intervention cannot fully achieve. Students must exercise regularly and eat healthily outside of school, which is hard for most interventions to achieve. 

I propose the TAF program shamed the kids so much they changed their lifestyles. The fat kids had to run around the school, while the normal weight kids watched them and ate lunch. The fat kids received calorie cash, while the normal kids could eat whatever they want. The fat kids would fail the annual fitness test, while the normal weight kids would get awards or pass easily. There was constant social pressure to lose weight, and as a result the fat kids changed their behaviors. 

This result fits a consistent finding in social science: One of the most effective ways to change behavior is to use social shaming. 

• Getting People to Vote: Reminding people their vote record is public and will be shown to neighbors is a very effective intervention to get people to vote. 

• Getting People to Stop Using too much Energy: Power bills compare your energy usage to your neighbors to reduce your usage. 

• Anti-drug: Making drugs seem “uncool” by peers through advertisements is the best messaging. Most other ads have no effect, or negative effects(kids are more likely to do drugs) 

People care a lot about what others think. 

Mental Health 

The obvious cost of this program is the mental health and feelings of the students. There is concern that the TAF program could cause eating disorders. Between the years 1994 to 2002, the number of newly diagnosed cases of Eating Disorders increased four-fold in Singapore. However, this rise corresponds with similar increases in western countries such as the United States and United Kingdom. In studies[1][2] of those with eating disorders in Singapore about 10% were part of the TAF program. The vast majority of patients were not part of the program. This evidence suggests that the TAF program did not cause large increases in the prevalence of eating disorders. Further, serious eating disorders are pretty rare. The lifetime prevalence of anorexia nervosa is 0.6%. The tradeoff is the following: We hurt the feelings of students in the TAF club and potentially increase the rate of eating disorders. In return, we get less overweight students who would live years longer and have a better quality of life. Is it more moral to fat shame or let the children be fat? Using purely utilitarian reasoning, the benefit of the 33% reduction of overweight children likely outweighs a small increase in prevalence of eating disorders.

However, this is not a strongly held belief. More evidence could cause me to update. A cool natural experiment somebody should do is comparing the kids who just missed the cutoff for the TAF program versus those who were just made the cutoff to see if program had an impact on adult weight/fitness levels and rate of eating disorders.

(I myself would not fat shame others)

Is it worth it? 

In the United about 15 million children are obese. A 33% reduction, would mean 5 million less kids were obese, extending their lifespans and improving their quality of life into adulthood, for minimal costs. However, it is very unlikely that this program would be implemented in the United States. Even Singapore, a much more authoritarian and paternalistic state, was forced to remove the program, due to complaints from parents. Though it is unlikely the United States could recreate the TAF program, we certainly should think more about physical education reform as a way to reduce childhood obesity and improve public health. 

Edit: I failed to mention what happened when TAF was replaced.

“In 2008, TAF was replaced with the Holistic Health Framework for all students, with the aim of generating more interest in a healthy lifestyle. But by 2012, an upward trend in childhood obesity re-emerged. By 2014, the rate had reached 12%.” - Source

In 2021, the childhood obesity rate is 16%. Source