Is Singapore winning the war against diabetes? What more can be done in fight against the chronic disease eight years on

SINGAPORE, Oct 26 — Singapore has recorded encouraging results since it launched war against diabetes in 2016 — with the the National Population Health Survey (NPHS) recording one in 12 Singaporeans having the chronic disease in 2022.

The numbers reflect a slight decline, from 8.8 per cent in 2017 to 8.5 per cent in 2022.

Experts however agree that much more had to be done, as the disease is not caused by a single factor but results from a combination of genetics, lifestyle, diet and environmental factors.

There are two main types of diabetes with type 1 diabetes generally associated with a genetic predisposition, where the body stops producing insulin and type 2 tends to be linked to lifestyle factors such as obesity and sedentary habits.

Both types of diabetes are serious and require ongoing care, but type 2 diabetes has a higher prevalence globally and in Singapore, and poses a significant public health challenge because of its link to long-term complications.

Novi Health co-founder Dr Sue-Anne Toh told Channel News Asia: “We didn't go up in terms of prevalence, and we even went down slightly. While this is a promising sign, it is still too early to come to a definitive conclusion.

“It's definitely in the right direction. Given that globally (the prevalence rates) are going up, we have been able to keep ours the same or even slightly lower, which is good,”

Diabetes, endocrinology and internal medicine consultant Dr Kevin Tan however reminded that managing type 2 diabetes remains difficult, as it involves complex interactions between biology, genetics and lifestyle choices.

National University of Singapore (NUS) Saw Swee Hock School of Public Health (SSHSPH) assistant Professor Ian Ang agreed, saying that to prevent people from getting diabetes in the first place, efforts have to take place outside of healthcare institutions, and get involved in people's daily lives.

Since 2016, Singapore has implemented several initiatives targeted at various risk factors for the disease, with one being obesity.

The National Population Health Survey (NPHS) in 2022 reported that the prevalence of obesity among Singaporeans steadily increased over the past decade, from 8.6 per cent in 2013 to 11.6 per cent in 2022 — prompting the government to promote regular exercise, healthy dietary habits, early disease detection and better disease treatment.

Even before it shifted gears on dealing with diabetes, the Health Promotion Board (HPB) had launched its Healthier Choice Symbol (HCS) in 2001, slapping its symbol on packaged food items to note healthier alternatives containing less salt, sugar or fat than other similar products.

HPB also marked certain foods, such as some cereals, with a label to indicate that they had a low glycaemic index (GI) which measures how quickly it raises blood sugar levels after consumption.

From 2016 however, the programme was expanded, with more foods — including convenience meals, legumes, nuts and seeds — with low GI marked out with the symbol to be more easily identifiable for consumers.

According to a Ministry of Health (MOH) report, as a result of this labelling programme, the market share of HCS products increased from 18 per cent in 2016 to 25.4 per cent in 2018 across 100 categories.

These include lower-sugar packaged beverages and sauces and wholegrain versions of rice, noodles and bread.

In December 2022, MOH also introduced Nutri-Grade labelling requirements and set advertising prohibitions for pre-packaged beverages, extending to freshly-prepared drinks last year.

The Nutri-Grade system labels beverages with grades ranging from A to D, with D being the unhealthiest.

Since then, the median sugar level of pre-packed Nutri-Grade drinks has gone down from 7.1 per cent in 2017 to 4.6 per cent in September 2023, and about six in 10 beverage outlets dealing with freshly prepared drinks are now offering less sweet choices by default.

In addition to Nutri-Grade system labelling, HPB launched the “Siu Dai by default” movement in the same month to complement the Nutri-Grade labelling requirement where beverage sellers who join the movement make their drinks with less sugar by default.

SSHSPH dean Professor Yik Ying Teo said that he counted the measure as a “major win” in the fight against diabetes.

“By labelling A, B, C or D on beverages as well as now on bubble tea and freshly prepared drinks, that has compelled more consumers to shift their preferences or shift their choices to healthier grades of A and B.

“All this has increased the awareness amongst the people that having too much sugar is not good for you.”

Allium Healthcare senior principal dietician Mary-ann Chiam said the challenge however lay in turning that awareness into long-term behavioural changes.

“Food habits are deeply ingrained and sustained.

“The progress is promising, but there's still work to be done.”

She said it is “preferable to start young,” highlighting HPB's efforts to eliminate sweet juices and sugary cereals from childcare centres and kindergartens aimed at fostering a lasting aversion to sweetened beverages, encouraging healthier habits from an early age.

Apart promoting healthy eating habits, another key initiative in the fight against diabetes is the Screen for Life programme, which encourages Singaporeans to undergo regular health screenings.

Under the scheme, Singapore residents aged 40 years and above can get themselves checked for chronic diseases such as diabetes, hypertension and hypercholesterolemia at a subsidised fee.

Singaporean adults can also use a self-administered diabetes risk assessment tool to determine whether they are at risk.

Experts are highly supportive of encouraging early screening, noting that the timely detection of diabetes can significantly improve long-term health outcomes by enabling early intervention and better disease management.​

Harmony Thyroid Endocrinology and Diabetes Centre founder and senior consultant endocrinologist Dr Vikram Sonawane said many type 2 diabetes cases are left undiagnosed for a long time because the condition tends to be asymptomatic in its early stages.

“This is why I always advise my patients with risk factors, especially those above 40 years old, to undergo routine screening for diabetes despite feeling perfectly well.”

In another move to encourage a more active lifestyle, HPB's National Steps Challenge, launched in 2015, was met with overwhelming success, with 1.7 million participants.

The challenge is a reward-based physical activity designed to encourage people to stay active: The more people walk, run or move in their daily lives, the more rewards they will get.

Since 2023, eligible Healthy 365 users have been auto-enrolled into the National Steps Challenge.

This year, HPB will be introducing a new set of features and milestone-based challenges on the Healthy 365 app.

It has been eight years since the launch of the war on diabetes, and progress has been slow — and experts caution that it may take more time before its impact can be fully evaluated as a long-term success.​

“Effects for chronic disease prevention initiatives will always take decades before the effects and expected trends can be analysed,” said Ang.

Diabetes consultant and past president of Diabetes Singapore Dr Tan said the war will not be won conclusively.

“We've seen shifts in people's habits, consumer buying patterns, industry buy-in and improved disease outcomes.”

Teo agrees saying it can be hard to determine the success of the number of people with diabetes as this number will always rise, given the ageing population.

“Diabetes is a long-term disease, so it's very difficult to attribute that some of these policy changes are the reason that diabetes rates such as prevalence rate have remained stable or fallen.”

Suggesting a more holistic measure of success including consumption patterns and how the F&B industry has responded to measures, other signs of winning the war would be if fewer people are suffering from complications from diabetes, such as vision problems or cardiovascular disease, he said.

“If there have been fewer and fewer people with such complications over the years, then it means that people are now much more aware that they have diabetes and are making the right effort to control the progression of diabetes.”

Tan noted that major lower extremity amputations have fallen from 116 to 66.3 per 100,000 patients from 2015 to 2019.

Lower body amputations signify a more severe complication of diabetes and mean that the disease has progressed to an advanced stage.

Singaporean health experts agree that much more has to be done as diabetes is not caused by a single factor but results from a combination of genetics, lifestyle, diet and environmental factors. — AFP

Sp what more can Singapore do?

One suggestion is to look to Chile, which slaps mandatory warning labels on products with high salt, sugar, saturated fat and calories on the front of the packaging, which has effectively changed consumer behaviour.

Researchers from the University of Chile and the University of North Carolina, Chapel Hill, found that Chileans bought 37 per cent less sugar, 22 per cent less sodium, 16 per cent less saturated fat, and 23 per cent fewer total calories three years after the labelling system was introduced.

The Chilean labelling system is considered more user-friendly, with messages on the front and back of certain packaged foods clearly detailing their high sugar, fat or calorie content.

Other suggestions include a sugar tax or more stringent mandatory food labelling laws could be considered too.

Over 50 countries have implemented taxes on sugar-sweetened beverages to date.

Notable examples include Mexico, which implemented such as tax in 2014, resulting in an 11 per cent increase in prices for sweetened beverages.

By 2016, Mexican consumers were buying 37 per cent fewer sweetened beverages, and researchers have estimated that the sugar tax has prevented 239,900 cases of obesity, 39 per cent of whom would have been children.

In the United Kingdom, a sugar tax called the Soft Drinks Industry Levy was introduced in 2018, so that drinks that contained high levels of sugar were taxed more.

This led manufacturers to reformulate their drink to reduce sugar levels in sweetened beverages.

Between 2015 and 2019, the percentage of drinks in supermarkets with sugar content of more than 5g per 100 ml fell from 49 per cent to 15 per cent.

And four years after the tax was introduced, the sugar content of the drinks subject to the tax had reduced by 43.7 per cent.

Toh however emphasised that diabetes is a disease that can be largely controlled by individual choices.

“Individuals need to take ownership of their own health. It all comes down to lifestyle decisions we make on a daily basis, and we cannot rely on the government alone.”