DPM Tharman Shanmugaratnam at the Opening Ceremony of the Ministerial Conference on Diabetes

Mindset Shifts, Innovation and Partnerships in the War on Diabetes

Excellencies,

Distinguished guests

Ladies and gentlemen

It is a pleasure for me to join you this morning for this inaugural international Ministerial Conference on Diabetes. I am glad that we have twelve Ministers, and other senior officials, from 18 countries and regions here today. Your presence demonstrates how serious the challenge of diabetes is, and how we can learn from each other as we respond to the challenge in our own countries. 

Not too long ago, diabetes was largely seen as a rich country disease, and there was not much global consciousness – even amongst governments – of the need to act. The reality is that diabetes is a pressing global health issue, plagues countries rich and poor, and has to be arrested to avoid significant cost in lives and national well-being everywhere. We have to put our collective minds and energies behind this issue.

• According to the WHO,  the number of adults living with diabetes has quadrupled since 1980.  
•  The cost of the disease on health, mortality and economies around the world every year is large. It has been estimated that the global annual healthcare expenditure on diabetes was over USD$700 billion in 2017. 

Diabetes is of particular concern for us in Singapore. Already, almost half a million Singaporeans live with the disease – that’s almost 1 in 9 persons, which is higher than the global prevalence. If nothing is done to change the trend, 1 in 7 persons will have diabetes in Singapore by 2050 (on an age-standardised basis). Without adjusting for ageing, it will be 1 in 6 persons. 

The situation is also worrying in other Asian countries. According to the Diabetes Atlas (2017), 1 in 9 persons in China suffer from diabetes, and 1 in 6 in Malaysia (age-standardised data).

The reality is that Asians are more likely to develop the disease. 60% of the world’s diabetic population is Asian. Research has suggested that Asians have more fat around organs and in the waist area than Europeans with the same BMI, which make us more prone to diabetes. 

We absolutely need to take diabetes seriously. This is why Singapore declared the War on Diabetes in 2016, and why our Prime Minister made the challenge of diabetes a theme of his annual National Day Rally speech last year. 

There is also a broader reason here. Fighting diabetes will help in fighting other Non-Communicable Diseases (NCDs) too. Diabetes shares common risk factors with cancer, high blood pressure and other chronic diseases – risk factors such as smoking, unhealthy diet, and lack of physical activity. Tackling diabetes will hence mean tackling other diseases, and is how we can ensure that our people live healthy and fulfilling lives.

Tackling diabetes requires three mindset shifts.

There are three mindset shifts that we must make if we want to effectively tackle diabetes – mindset shifts among governments, employers and citizens. Singapore’s war on diabetes in fact involves mobilising our entire society. This is the approach in several other countries too, like Finland, United Kingdom, and Australia.

Government mindset shifts

The first shift is to look at the government’s responsibilities as extending beyond health ministries. We must take a coordinated, whole of government approach to promote healthy lifestyles.
 
What people do day-to-day, as part of their regular activities, can be decisive in shaping their health outcomes – and the levers or influences that governments have go well beyond the healthcare sector. We want to go beyond healthcare, to health – don’t wait until diseases set in before intervening, but find all ways and means to make healthy living convenient, enjoyable and rewarding. 

Every sector has to be involved. We are encouraging our food and beverage sector to switch to healthier ingredients, and highlighting meal options with lower calories to help consumers make healthier choices, through the Healthier Dining Programme introduced by the Health Promotion Board (HPB). About half of the hawker stalls in our 114 hawker centres, and 1,200 coffee shops, were providing at least one healthier option in 2017. There is still a long way to go in the F&B sector, and we are stepping up on this. 

Beyond the Health Ministry, we are trying to influence people’s choices and habits for the better:

•  Our infrastructure agencies are placing fitness corners in our housing estates, and developing an extensive Park Connector Network of cycling and running paths through our various parks. 
• The National Environment Agency (NEA) will be installing more water dispensers to encourage consumption of plain water at more hawker centres. This is in support of a ‘Drink Plain Water’ recommendation raised by Singapore’s first community-based Citizens’ Jury on the War on Diabetes (the Ministry of Health collaborated with the Institute of Policy Studies to engage the public in generating ideas to deal with the problem).

Our public agencies will be doing more to work together to catalyse change, and nudge Singaporeans towards adopting healthier lifestyles. Just this year, Singapore launched a new inter-agency Taskforce, to drive efforts by different agencies and to better coordinate their ground programmes – we will call this the HealthySG Taskforce.

Employer mindset shift

The second mindset shift we need to catalyse is for employers to promote good health at the workplace. The intuitive conclusion that healthy employees are more productive employees has been borne out by research.  

Conversely, poor health not only affects business productivity, but also poses a serious risk to workplace safety. In particular, poorly managed diabetes can lead to giddiness, sudden loss of vision, or heart attacks. It can be especially dangerous for jobs involving operating machinery or vehicles, or working at heights. 

There are good examples of how we can get employers to play a greater role in the health of their workers. For example, the US National Institute for Occupational Safety and Health’s “Total Worker Health” programme integrates the management of employees’ safety risks with workplace health promotion. They found that educating workers on the effects that ill health may have on their safety, will result in greater effort to improve health.

In short, poor safety can affect health through injuries, while poor health can compromise safety. In Singapore, the Workplace Safety and Health (WSH) Council and HPB have therefore worked together to put in place a Total Workplace Safety and Health (Total WSH) approach. 

There are some good examples of local employers taking responsibility for Total WSH and seeing the business case for this. 

For instance, SBS Transit Ltd, one of our main public transport operators, worked closely with its union partner, the National Transport Workers Union, to adopt Total WSH to enhance the well-being of its bus captains.

• SBS provides all its bus captains with free health screening and follow-up coaching on how to change their diets and lifestyles. 
•  But beyond that, it also supports its bus captains with chronic conditions such as diabetes, through modified work schedules for example. Bus captains may request to be assigned to shorter feeder services to allow timely medication and food intake to regulate their blood glucose levels.

 
A second example. Keppel Offshore & Marine, one of Singapore’s largest firms in rig and ship building and repair, has also adopted this approach. Safety is critical in Keppel’s projects that involve work-at-heights and lifting heavy objects. 

• They recognise that good health is key to this. 
• An on-site Keppel Wellness Centre was set up at Keppel Shipyard in 2017 to promote Total WSH to all its employees. The company also reviewed and modified work processes to promote better work ergonomics and prevent ill health and safety-related incidents. Keppel also provides an in-house doctor and occupational health nurse, to monitor employees with chronic conditions.
• Like SBS, Keppel also provides all its workers with health screening, and the follow-up support for workers with diabetes and other conditions. 

Since we put the Total WSH framework in place in 2014, about 200,000 workers already have access to Total WSH services, such as workplace safety and health risk assessment, health screening and follow-up interventions, and work redesign for those with health conditions.
  
Many more employers must play their responsible role. Over the next three years, we want to increase access to Total WSH services to half a million workers, and take it further over time. We will make it more convenient for companies and their employees. On top of the current Total WSH Services centre in Woodlands East Industrial Estate, the WSH Council will be locating two more Centres by 2020, in the central and eastern parts of Singapore. The Centres will allow for more affordable health screening, follow-up check-ups, and advice on how to promote health within the workplace.    

Individual mindset shift

The third mindset shift – and the most critical one – has to be among all of us as individuals, wherever we are. It is the individual who has to see the benefits of adjusting his or her habits, and feel good about doing so. 

As it stands, however, exercising more and eating healthier stuff is almost always at the top of the list of failed new year resolutions. So there is a lot to be done here. 

First, there has to be sustained effort at putting out information on the health risks of diabetes, and how serious the issue is to each of us. We have to tackle a basic problem in human psychology – the pleasures of a slice of chocolate cake are immediate, while the costs to health are hidden and set in much later, but with potentially severe consequences. So we need to do much better in our public communications, and put into the public consciousness the importance of eating well so that we have lasting satisfaction in life, and are responsible to our loved ones. 

We must in particular channel more resources into education on the lifestyle modifications that we must do, well before any indication of diabetes sets in. These lifestyle modifications are extremely important, and can reduce the risk of people developing diabetic conditions by 40% - 70%. 
 
Second, we must do more to get people to go for early screening so that they can take action early to change their lifestyles. Far too often, people find out they have diabetes only when severe symptoms manifest. 

Last year, we enhanced the Screen for Life Programme to reach out to those who are still unscreened in our population. Costs should not be a barrier to screening and care. Singaporeans over 40 now pay no more than five Singapore dollars for a set of essential screening tests done every three years, and the first follow-up consultation for those who need it. The uptake has been encouraging. Close to 46,000 persons were screened under the programme in the first 12 months after we enhanced it, compared to just 1,300 in the year before its implementation.

We are now studying how we can make screening virtually universal in the population, by making it convenient and easily accessible. One approach involves making available tests that do not require fasting in advance, and can hence be done opportunistically. 

We also want to better incentivise individuals to take preventive measures early, rather than face the consequences of the disease later.

•  HPB’s popular National Steps Challenge (NSC), currently in its fourth season, gives out a free steps tracker that encourages individuals to be more active through corporate challenges, gamification, and earning health points. 
• This is integrated with HPB’s Healthy365 app, where individuals can also earn additional health points by purchasing healthier food items through the Eat, Drink, Shop Healthy (EDSH) Challenge. As of end Oct 18, 540,000 people have signed up for EDSH -  a good start as we began the scheme in Aug 2017.
• These points can then be redeemed for rewards.

This has had some good early success. We have seen in the National Steps Challenge that over time, participants have become more conscious of their activity levels and more have made walking a habit. (In 2017’s challenge, 16% of the  participants continued to clock a daily average of over 7,500 steps, even after the Challenge ended.) 

We can learn from best practices from other countries, such as the United Kingdom. In the UK, healthcare professionals in the National Health Service (NHS) assess a person’s risk based on their BMI, family and medical history, before inviting them for health checks. By implementing small changes in the way patients are invited to attend health checks – such as text message reminders – uptake was increased by 12 percentage points, and the NHS has been able to diagnose many more cases.

Third, we must act more decisively to develop good eating habits from young, to shape the tastes and preferences of our children. 

• 70% of children who are overweight at age 7, remain overweight as adults. This has a direct impact on chronic diseases such as diabetes.

We are putting more effort in our schools.

• Sugary drinks, such as syrup and cordial, and drinks without the Healthier Choice Symbol (HCS) are not allowed in our schools, including our pre-schools. 
• We also have a Healthy Meals in Schools Programme, to ensure students have well-balanced meals for their growing needs. 

But there is still much to do to change eating habits among children, including adolescents. A lot depends on what happens daily outside of school hours, and over weekends and the holidays. 

• Our National Population Health Survey (NPHS) tells us, as we would expect, that parents heavily influence what their children consume.
• Children whose parents consume more sugar-sweetened beverages, are much more likely to consume more of such drinks themselves. 
• Parental education is hence critical. Parents must understand that when we invest resources and time in developing our children, helping them develop healthy habits for life has to be a part of this. And it has to start young.

Innovation and Partnerships will support this effort.

To support our efforts in catalysing these mindset shifts, we also need to identify and facilitate the spread of innovative solutions, and strengthen partnerships in our joint efforts to tackle diabetes.

There are many promising areas where innovation can be a game-changer, be it in technology, policy or behavioural nudges.

One example is Faesol (pronounced as “fay-soul”) - a Singaporean SME at the forefront of food innovation.

• With the support given under HPB’s Healthier Ingredients Development Scheme (HIDS), Faesol has developed healthier, ready-to-mix Asian beverages for coffee shops and food service establishments.
• Faesol leveraged its home grown technologies and ingredients to match the taste and characteristics of sugar in food products, using powder processing capabilities to make beverage mixes that are free of preservatives, more shelf stable, and easier to prepare. 
• Local beverages, such as water chestnut, pearl barley and Roselle tea can now taste good even with low sugar or no sugar. 
• Faesol is now exporting its products to other countries, such as Hong Kong, New Zealand and Australia.

We must also do more together internationally. Today’s Conference is a good step in that direction. There’s much we can learn from each other, to adopt best practices, discover and spread innovative solutions, and share what works and what doesn’t work as well.  

It is indeed easier to achieve the mindset shifts I spoke about when they become the norm across countries. It happens when norms on what healthy eating habits are converge, across our very different cuisines; when we create global demand for healthier food, and shaping global food supply chains; when smoking is unfashionable everywhere; and when modern lifestyles everywhere involve regular exercise, and major employers everywhere see as their responsibility to encourage their employees to live healthily. 

Conclusion

Tackling diabetes, and other NCDs, will not be a simple task. It will require a sustained multi-year effort, targeted at shifting mindsets, nudging people to change behaviour and feel good about it, and spreading innovative solutions. But it is a worthwhile and necessary endeavour, for the well-being of our people.

I hope this conference spurs greater collaboration, and that you find the next two days an enriching experience.