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.
Chia Kee
Seng and Benjamin Ng
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.
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