The value of prevention in the war on diabetes

By Chia Kee Seng and Benjamin Ng, Published The Straits Times, 23 Apr 2016

Minister for Health Gan Kim Yong recently declared war on diabetes in Singapore.

This clarion call for government agencies, the private sector and the rest of the community to go all out to fight the disease is timely and much needed. It also underscores the Government's intent to invest immense resources in new initiatives and programmes to fight the disease.

But why is it necessary to single out diabetes and take such bold, multi-sectoral action against a single disease?

When we consider the current and projected number of diabetics, the severity of diabetes-related complications and the enormous costs to both the individual and country, the rationale becomes clear and self-evident.

Singapore is home to more than 400,000 diabetics today. Estimates suggest that diabetes will affect almost 670,000 people in 2030, and an alarming one million by 2050 if we do not act now to arrest this trend. This increase is not merely due to an ageing population. It is also caused by the rapid rise in the proportion of overweight and obese young adults. In addition, today, there are about 10,000 patients who are suffering from the complications of diabetes. That is expected to increase to at least 25,000 by 2050.

Diabetes, with its complications, exerts a staggering toll on the country with increased healthcare expenditure, loss of productivity and the psycho-social burden on society. A recent study by the NUS Saw Swee Hock School of Public Health and University of Southern California estimated that in 2010, diabetes among the working population cost Singapore more than $1 billion, and that figure is likely to exceed $2.5 billion by 2050.

As with any warfare, a well-planned strategy is crucial. Mr Gan identified five fronts on which this war would be fought: prevention, screening, control, education and stakeholders' engagement. What is particularly refreshing about this war plan is the major shift towards preventing the onset of diabetes and engaging every stakeholder.

In the past, the emphasis was on the treatment of diabetics: treatment protocols, right siting of patients and the stratification of patients according to risk of complications. There is strong evidence that good control of blood sugar can reduce the risk of and delay the onset of complications, including renal failure, heart attacks, stroke, blindness and lower limb amputations. However, the risk of complications is increased even among pre-diabetics ,whose blood glucose levels are higher than normal but not high enough for a clinical diagnosis of diabetes. Moreover, many diabetics are unaware of their disease. By the time diabetics enter the healthcare system, they are already at higher risk of developing the dreaded complications.

Prevention is based on targeting two important risk factors: unhealthy diet and inadequate exercise. Proper diet and regular exercise play integral roles in reducing or halting the trend of rising obesity. This is not easy, and we cannot be doing more of the same: telling and urging individuals to live healthily through the mass media, campaigns and mass activities that do not lead to sustainable behavioural change.

Behavioural research has highlighted the importance of macro-level environmental measures that create "healthy living as a default" or simply, making it easier for an individual to adopt healthier lifestyles.

Fortunately, many of our upcoming national-level developments promote the increase in physical activity as part of daily living. For instance, the plan to have 85 per cent of residents live within 400m of a park, opening up 900ha of reservoir area and 100km of water- ways for recreational activities, going "car-lite" and providing 700km of cycling paths to turn this into a "walking and cycling" city.

A bigger challenge is diet. Eating is the national pastime. Singaporeans are conditioned, from a young age, to eat certain types and amounts of food. Many overeat and eat unhealthily. A high proportion of young adults (aged 18 to 29 years) prefer food items such as sodas, fruit juices and refined carbohydrates, all of which increase the risks of obesity and diabetes.

Many advocate a sugar tax, citing the success of the tobacco tax. However, sugar and tobacco are rather different commodities. Taxation is generally a blunt instrument. A tobacco tax is very specific and easier to administer. It is difficult to administer a sugar tax unless it is restricted to specific items like sodas. Instead of imposing a sugar tax, efforts could be made to engage the food and beverage industry more actively and recruit it as an ally that offers healthier product offerings, advertises responsibly and encourages healthy eating.

Environmental changes at the macro level must also sync with behavioural changes at the individual level. Individuals must be empowered to make the right choices at the point of decision. This is a highly complex area that still requires much research, especially from the sociological and behavioural perspectives. However, there are a few obvious touchpoints, with the first being a broad-based health education targeting the young and the elderly, which takes into account how both target groups acquire information and form mindsets. The goal is not for people to increase knowledge but to change attitudes.

The second obvious touch point is to promote behavioural change in the workplace. With employees spending up to one-third of the day at work, the workplace offers a conducive environment to foster healthier eating habits and lifestyle. There are overseas examples of workplace-centred diabetes prevention and management programmes. Locally, the Ministry of Health and Ministry of Manpower launched the Total Workplace Safety and Health to help employers and employees go beyond a workplace safety culture to a safety and health-promoting culture.

Finally, it is very refreshing that the war is moving beyond hospitals and healthcare to providing good health - that means nurturing a healthy nation and people. This paradigm shift will require healthcare workers to move out of their treatment- and patient-centric comfort zone to a new approach of being prevention- and population-centric. The six regional health systems will have to be transformed to being six operators of a single national health system. This war on diabetes is a great opportunity to further transform the regional health systems.

War has been declared. We have the armaments. We need to assemble the troops. It will be a long war but Singapore will succeed. We will not have one million diabetics, come 2050.

Prof Chia Kee Seng is the dean and professor of the Saw Swee Hock School of Public Health at the National University of Singapore, and Dr Benjamin Ng is the president of the College of Public Health and Occupational Physicians at the Academy of Medicine, Singapore.