8 years ago, Singapore declared war on diabetes. Is it winning?

Diabetes is a global health crisis, particularly type 2 diabetes, which is heavily influenced by lifestyle habits, and numbers are increasing every year. Ever since launching the war on diabetes, Singapore has been aggressive in dealing with the chronic illness, but is there more to be done?

Since Singapore launched its war against diabetes in 2016, the results have been just slightly encouraging. 

According to the latest available figures from the National Population Health Survey (NPHS), one in 12 Singaporeans had diabetes in 2022.

This represented a slight decline in the prevalence or overall rate of diabetes, from 8.8 per cent in 2017 to 8.5 per cent in 2022.

Speaking to CNA TODAY, experts cautiously welcomed the slight improvement but added that plenty more could be done.

Dr Sue-Anne Toh, co-founder of Novi Health, a private clinic specialising in diabetes and weight management, said: "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," said Dr Toh, who is also an adjunct Associate Professor of Medicine at Yong Loo Lin School of Medicine at the National University of Singapore (NUS)

Experts also noted that diabetes is a chronic and complicated disease that 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: Type 1 diabetes is generally associated with a genetic predisposition, where the body stops producing insulin. 

While type 2 diabetes has a genetic component, it also 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.

More studies are also showing that type 2 diabetes is not an age-related chronic condition and can affect a person at any stage of life. 

While there have been new drugs to manage diabetes, Dr Kevin Tan, a consultant in diabetes, endocrinology and internal medicine, said that managing type 2 diabetes remains difficult, as it involves complex interactions between biology, genetics and lifestyle choices. 

Sharing his sentiments, Assistant Professor Ian Ang from Saw Swee Hock School of Public Health (SSHSPH) at NUS 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.

DIABETES AS A GLOBAL HEALTH CRISIS

Singapore is certainly not the only country in the world grappling with diabetes. 

The latest findings from the International Diabetes Federation (IDF) show that in 2021 alone, 537 million adults around the world between the ages of 20 and 79 were living with diabetes, nearly double the 366 million recorded in 2011. 

In its 2021 Global Burden of Disease Study, the medical journal Lancet reported that this number is expected to balloon to more than 1.31 billion people by 2050, which will represent a diabetes prevalence rate of 9.8 per cent.

The Lancet noted that this rise is being driven almost entirely by type 2 diabetes, which accounted for more than 96 per cent of diabetes cases worldwide in 2021. 

The rise in diabetes prevalence puts pressure on healthcare systems around the world. The IDF found that in 2021, healthcare expenditure for diabetes reached US$966 billion (S$1,275 billion) and is slated to reach more than US$1,054 billion by 2045. 

The study from The Lancet added there is an urgent need to tackle the rise of risk factors for type 2 diabetes, particularly obesity. 

Without intervention, diabetes will continue to "exert increasingly negative effects on the quality of life of individuals, the health of populations, and the strength of global economies for decades to come", it said.

This effect is further compounded in rapidly ageing populations, the IDF said, with the highest increases in diabetes prevalence expected to occur in middle-income countries due to their ageing populations. 

NOT SO SWEET 

Since the war on diabetes began in 2016, Singapore has implemented several initiatives targeted at the various risk factors for the disease.

One risk factor is obesity. The NPHS in 2022 reported that the prevalence of obesity among Singapore residents steadily increased over the past decade, from 8.6 per cent in 2013 to 11.6 per cent in 2022. 

As such, the government moved to promote regular exercise, healthy dietary habits, early disease detection and better disease treatment. 

Even before the war on diabetes began, the Health Promotion Board (HPB) launched its Healthier Choice Symbol (HCS) in 2001.

If a buyer sees the HCS symbol on a packaged food item, it means the product is a "healthier alternative", containing less salt, sugar or fat than other similar products. 

HPB also began marking out certain foods, such as some cereals, with a label to indicate that they had a low glycaemic index (GI). A food's glycaemic index (GI) measures how quickly it raises blood sugar levels after consumption. Higher GI foods cause a faster spike in blood sugar, while lower GI foods result in a slower, more gradual increase. 

To complement the war on diabetes, in 2016 the programme was expanded, and more foods with a low GI were marked out with the symbol, to help buyers easily identify them. These included convenience meals, legumes, nuts and seeds.

According to a Ministry of Health (MOH) report on the war on diabetes, 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 these to include freshly prepared drinks last year. 

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

This has effected change: 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. Beverage sellers who join the movement make their drinks with less sugar by default.

Professor Yik Ying Teo, dean of the SSPH at NUS, said that he would count this 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," said Prof Teo, who is also the vice president overseeing the university's Office of Global Health.

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

But Ms Mary-ann Chiam, the senior principal dietitian at Allium Healthcare, said the challenge lies in turning that awareness into long-term behavioural changes.

"Food habits are deeply ingrained and sustained," she noted. 

She said it is "preferable to start young," highlighting HPB's efforts to eliminate sweet juices and sugary cereals from childcare centres and kindergartens. These initiatives aim to foster a lasting aversion to sweetened beverages, encouraging healthier habits from an early age.

"The progress is promising, but there's still work to be done," she added.

For Mr Navin Nambiar, 43, the wake-up call came when he was diagnosed with diabetes five to six years ago after undergoing a medical check-up during reservist.

"I had to change the way I eat. I'm a sugar freak. In between lessons, I used to down a packet drink," said Mr Navin. 

He added that it was a habit he had carried over from his primary school days when sugary drinks were all he drank during recess. 

Now, he's a stickler for labels, which have helped him control his sugar intake.

"I'd never cared about the grading. And now, I am the most 'on' person," said Mr Navin, who actively eschews any drink with a 'C' Nutri-Grade rating or worse. 

In addition to 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 who spoke to CNA TODAY were highly supportive of moves to encourage early screening, noting that the timely detection of diabetes can significantly improve long-term health outcomes by enabling early intervention and better disease management.​

Dr Vikram Sonawane, a senior consultant endocrinologist and founder of Harmony Thyroid Endocrinology and Diabetes Centre, said many cases of type 2 diabetes 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," said Dr Vikram. 

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. 

This involves 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. 

HOW TO TELL IF WE'RE WINNING THE WAR

It has been eight years since the launch of the war on diabetes, and while Singapore has made some progress, 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 Asst Prof Ang.  

Dr Tan, the diabetes consultant who is also the past president of Diabetes Singapore, added: "Knowing how difficult an enemy diabetes is worldwide and its inexorable increase over the past decades, the war will not be won conclusively."

He noted that the War on Diabetes was never going to show quick results, but that it was necessary, and has already brought about positive changes.

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

Moreover, Prof Teo said that since diabetes is a chronic condition, 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," said Prof Teo. 

Instead, Prof Teo suggested a more holistic measure of success. 

This includes consumption patterns and how the F&B industry has responded to these 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.

He added: "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."

For example, Dr 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. 

WHAT OTHER COUNTRIES HAVE DONE 

In the global fight against diabetes, Finland and Japan are two countries that seem to have succeeded, by managing to stabilise their numbers. 

The IDF reported Finland's diabetes prevalence at 6.1 per cent in 2021 and Japan's at 6.6 per cent, compared with Singapore's 11.6 per cent in the same year.

The Finnish Diabetes Prevention Study (DPS), which started in 1993 and ended in 2001, was the first in the world to demonstrate that type 2 diabetes can be prevented by modifying eating habits and physical activity.

Finland then established a Development Programme for the Prevention and Care of Diabetes in 2000, which ran until 2010 and focused on preventing type 2 diabetes through lifestyle interventions and improving early detection and care.

It introduced national screening programs, promoted physical activity and healthy diets, and collaborated with primary healthcare providers to monitor at-risk individuals, ultimately contributing to a reduction in diabetes incidence among targeted groups.

The high-risk individuals who were identified and roped into the programme were found to have a 69 per cent lower risk of type 2 diabetes after a one-year intervention, and on average were able to lose 5 per cent of their weight.

Meanwhile, Japan started its National Health Programme in 2008 to ensure early intervention and prevention of diabetes. This targeted individuals aged 40 and above and included health screenings and educational support. 

More than half of the country's population aged 40 to 74 received check-ups as a result and the programme achieved a 25 per cent reduction in the risk of diabetes among the patients with pre-diabetes.

People with pre-diabetes have blood sugar levels that are higher than normal but not high enough to meet the criteria for type 2 diabetes. Being pre-diabetic serves as a warning sign that a person is at an increased risk of developing diabetes and other complications.

WHAT MORE CAN SINGAPORE DO?

Singapore has made strides when it comes to managing the condition, and those who live with type 2 diabetes agree that the government's initiatives has made living with the disease much more manageable. 

Ms Maureen Ng, 76, a housewife, who has been diagnosed with type 2 diabetes, shares a similar experience with having a sweet tooth and penchant for nyonya kuehs.

"Before I was diagnosed, I didn't control my diet… Then I realised that it is not a lifestyle that I should carry on."

Along with watching her diet, Ms Ng has also participated actively in The National Steps Challenge since its first season in 2015. 

She said the rewards gave her an incentive to exercise more and helped to manage her sugar levels, especially after a heavy meal.

"I just walk around my estate a couple of times, and it clocks in about 5,000 steps and it helps me feel better," said Ms Ng, who has since made daily walks part of her routine.

Still, some experts agree that more can be done to curb diabetes.

Ms Chiam said that while Singapore's approach is comprehensive, it can also look abroad for inspiration.

For example, Chile 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.

Even though Singapore has a labelling system too, Ms Chiam said the Chilean version is more user-friendly, with messages on the front and back of certain packaged foods clearly detailing their high sugar, fat or calorie content.

“Chile's system may offer a more straightforward approach with its clear, easy-to-understand front and back of pack warnings,” said Ms Chiam, adding that Singapore could benefit from a similar system, paired with ongoing education and support for healthy eating from a young age. 

She added that more aggressive measures such as a sugar tax or more stringent mandatory food labelling laws could be considered too, particularly when tackling the consumption of sugary beverages and highly processed foods.

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.

But even if the Singapore government were to take a leaf out of these countries' books and step up its policies, Dr Toh of NUS 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," said Dr Toh.

Mr Navin said: "Type 2 diabetes can be beaten… and I'm hell-bound on beating it. It's all in the palm of your hands, whether or not you want recover, and I want to recover."

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