1. As part of Singapore’s War on Diabetes, the Ministry of Health (MOH) is studying measures to better support pre-diabetic persons in managing their condition.
2. About 430,000 (or 14 per cent of) Singaporeans, aged 18 to 69 years, are diagnosed with pre-diabetes. This is a condition where individuals have higher than normal blood sugar levels, but not high enough to be diagnosed with diabetes. Without intervention, one in three individuals with pre-diabetes is likely to develop Type 2 diabetes within eight years.[1] The large number of pre-diabetics underscores the significance of diabetes as a serious public health concern in Singapore.
3. Progression from pre-diabetes to Type 2 diabetes is preventable, through early diagnosis, appropriate management and follow-up. This avoids downstream medical complications, which often result in poorer health outcomes and more costly treatment for the patient. Lifestyle interventions such as proper nutrition, physical activity, and weight management can effectively slow, and in some cases, reverse the progression of pre-diabetes to diabetes. [2]
4. Minister for Health, Mr Gan Kim Yong, said, “As Singapore commemorates World Diabetes Day 2017, we will continue to encourage and empower Singaporeans to take charge of their health and live their lives free from diabetes. Awareness and early intervention of pre-diabetes play a critical role in our fight against diabetes. We hope that with greater support, pre-diabetic individuals will take more active steps to manage their condition, for better long-term health outcomes.”
5. Minister for Education (Schools) and Co-Chairman of the national Diabetes Prevention and Care Taskforce, Mr Ng Chee Meng, said, “In schools and Institutes of Higher Learning (IHLs), we have made good progress under the NurtureSG Plan, which aims to cultivate healthy lifestyle habits from young, including healthy eating and regular physical activity. For example, some schools have started to provide even more opportunities for physical activity by increasing accessibility to sports equipment and facilities beyond formal curriculum hours. To ensure that children receive nutritious, balanced and varied meals, all mainstream schools now implement the Healthy Meals in School Programme. HPB’s healthier meals programmes will also be intensified at the pre-school and IHL levels. We will continue to work with relevant stakeholders, such as parents, employers and industry partners, to promote healthier diets and active lifestyles among Singaporeans, so as to reduce Singaporeans’ risk of developing diabetes.”
Exploring better support for the cost of managing pre-diabetes
6. In line with one of the Diabetes Prevention and Care Taskforce’s key strategic thrusts to facilitate early detection and intervention, MOH is exploring ways to better support pre-diabetic patients in identifying and managing their conditions, including through the use of Medisave under the Chronic Disease Management Programme (CDMP), as well as the Community Health Assist Scheme (CHAS). More details will be announced when ready.
7. This will complement the existing suite of initiatives and programmes for persons with pre-diabetes, such as HPB’s Diabetes Prevention Programme, and the Screen for Life initiative. (Please see details in Annex A.)
Healthy Living
8. MOH will continue to create a conducive environment for Singaporeans to adopt a healthy lifestyle. To encourage more Singaporeans to adopt healthier diets, the Health Promotion Board (HPB) has launched several initiatives to improve the quality and quantity of meal options in hawker centres and food courts under the expansion of the Healthier Dining Programme (HDP). As of end-October 2017, more than 4,000 food and beverage (F&B) stalls across 70 hawker centres and 600 coffee shops have joined the HDP and offered at least one healthier option in their menu. Moving forward, HPB aims to ensure that by 2019, 40 per cent of stalls across all hawker centres and coffee shops will have at least one healthier option on their menu.
9. To increase the diversity of healthier food options for consumers and encourage industrial innovation in the development of healthier food products, HPB launched the Healthier Ingredient Development Scheme (HIDS) in July 2017. MOH aims to invest $20 million over the next three years to improve the quality of staples such as wholegrain rice and noodles, as well as cooking oils that Singaporeans consume regularly. The scheme provides support in the areas of product development, marketing and trade promotions, to increase the adoption of healthier ingredients in the food service sector and improve consumer’s access to healthier meals. As of end-October 2017, six oil manufacturers and four wholegrain manufacturers have applied for support under HIDS.
10. HPB is also partnering with the Food Innovation Resource Centre (FIRC) at Singapore Polytechnic to develop diabetic-friendly noodles for a start, since noodles are one of the key staples consumed regularly by Singaporeans. These prototypes can be used by noodle manufacturers, to be further developed and packaged into consumer-friendly products, not just for the Singapore market but also for the overseas market. FIRC is also developing the Glycaemic Index Speed Test (GIST), an in-vitro test to provide the food industry with a faster and cheaper solution in determining the GI of food products, by replacing human volunteers with lab-based digestion and analytical methods. The in-vivo gold standard will then be used for the final validation.
Exercise
11. To rally and encourage greater community participation in the War on Diabetes, this year’s National Steps Challenge has been extended into the community with the new Community Challenge 2017. The Challenge, which will run from 26 November 2017 to 31 March 2018, aims to rally individuals from all 89 constituency divisions in Singapore to be more physically active. Steps taken by residents will contribute to their constituency division’s daily average, which will subsequently be converted into donations for the President’s Challenge 2018.
Early Detection and Intervention
12. Regular screening is one of the key strategies to help Singaporeans take charge of their health and improve early detection of pre-diabetes or Type 2 diabetes. In line with this strategy, the Diabetes Risk Assessment (DRA) tool was launched to encourage adults aged 18 to 39 years to assess their current risk for undiagnosed diabetes. Since its launch on 1 September, about 44,000 users aged 18 to 39 years have used the DRA. Around one-fifth of them, or about 8,500, were found to be at higher risk.
Managing Diabetes
13. The control of diabetes, and prevention or delay of complications, can be enhanced through equipping patients for self-care and the holistic management of diabetes patients by their regular family doctor. MOH is working closely with family doctors to enable more effective management of diabetes in the community, as well as to empower patients in their self-care needs. A key initiative includes bringing GPs together in Primary Care Networks (PCNs), to provide comprehensive team-based care and better-resourced support services for patients with diabetes and more complex chronic conditions. For patients, MOH is developing a Patient Empowerment for Self-care Framework that will help them initiate and sustain their lifestyle changes, and improve their adherence to the treatments for better control of their condition.
14. The War on Diabetes is a whole-of-nation, whole-of-society effort. Even as the government does its best to provide a supportive environment, health is ultimately a personal responsibility. While we can nudge Singaporeans to change their lifestyles, the decision to make healthier lifestyle choices lies with the individual. All of us have a part to play in beating diabetes.
MINISTRY OF HEALTH
14 NOVEMBER 2017
ANNEX A
Care Guidelines and Programmes for Persons with Pre-diabetes
Appropriate Care Guide (ACG):
· MOH published an Appropriate Care Guide (ACG) on “Managing pre-diabetes” in July 2017. The ACG complements the Diabetes Clinical Practice Guidelines, which were issued in 2014. The ACG equips clinicians with a systematic management pathway to improve follow-up of persons with pre-diabetes. It provides guidance on tailoring lifestyle intervention, such as healthy diet and increased physical activity, to individual needs for effecting sustained behavioural changes. If intensive lifestyle intervention is insufficient to improve a patient’s blood glucose status, the ACG recommends doctors to consider metformin in overweight patients.
HPB’s Diabetes Prevention Programme (DPP):
· The Diabetes Prevention Programme (DPP) is a 12-week programme developed for participants who are pre-diabetic. Participants will learn ways to achieve better blood sugar control and sustain healthy lifestyle practices to prevent or delay progression of diabetes. The first six weeks of the programme comprise two nutrition workshops, nine exercise classes and one goal-setting workshop conducted over two sessions every week. The subsequent six weeks will be a self-guided phase. Monthly SMS health tips will also be sent to participants for the remainder of the year. Participants will be required to undergo an Oral Glucose Tolerance Test at the end of one year to determine whether their condition has improved.
· Participants are recruited from polyclinics and the programme is held at a place that is convenient for them. The programme requires a high level of commitment and some 150 Singaporeans have benefitted from this programme since its introduction in 2015. More than half were found to have achieved normal glucose levels one year after intervention.
Diabetes Prevention HealthHub Track
· In April 2017, HPB launched a complementary personal health management app on the HealthHub Track. With this, pre-diabetics can self-monitor physical activity levels, and learn how to make healthy lifestyle modifications to manage their conditions. As of October 2017, there have been 25,770 downloads of HealthHub Track, of which about 1,800 were of the pre-diabetes module.
Enhanced Screen For Life subsidies:
· To encourage more Singaporeans to go for regular health screening and follow up, so as to facilitate early detection and intervention, MOH has enhanced government subsidies for the Screen for Life (SFL) programme from 1 September 2017.
· Under the enhanced SFL programme, CHAS cardholders need only pay $2 for their screening test and first post-screening follow up consultation, and Pioneers will not need to pay. All other eligible Singaporeans need only pay a small fixed fee of $5.
Diabetes Risk Assessment (DRA) tool:
· The DRA tool on HealthHub was rolled out on 1 September 2017 to encourage younger adults aged 18 to 39 years to assess their current risk for undiagnosed diabetes and based on the assessment, determine if they should go for diabetes screening. These individuals can qualify for the enhanced SFL subsidies if they have been assessed to be at a higher risk of diabetes.
· We will also encourage the use of the DRA at workplaces that have a large population of employees under 40 years old e.g. in the public sector, financial services, and the retail and educational sectors.
· To also further increase the uptake of diabetes screening among younger women with a history of gestational diabetes, we are also exploring to allow them to have access to SFL subsidies without needing to complete the DRA.
[1] Wong MS, et al. Diabetes Care. 2003.
[2] Two landmark trials in the US and Finland found that lifestyle modification halves the risk of developing diabetes, among those with pre-diabetes. Baker MK, et al. Diabetes Research and Clinical Practice. 2011.