Dr Kevin Tan, President of Diabetes Singapore
Mr Chua Song Khim, Deputy Chief Executive of National University Health System
Distinguished guests, partners and friends of the community
Ladies and Gentlemen
Good morning to all of you.
2 Diabetes is a very serious problem confronting Singapore and also globally. Probably because of affluent lifestyle, diets and so on, we have come to deal with a problem that is affecting one in three Singaporeans who is at risk of developing diabetes at some stage in their lifetime. Of those who are diagnosed with diabetes, one in three has poor control of their condition and that is increasingly a problem because once you have no control of the condition, there will be serious complications such as foot amputation which is hitting a very high number in Singapore, kidney failure, heart disease and stroke.
ADVANCEMENT IN DIABETES MANAGEMENT
3 We declared a War on Diabetes in 2016 and in conjunction with this year’s World Diabetes Day, we have published our summary report, to give you a status of what we have done so far, what are the steps we have taken, what have been successful, and to also look forward on what are the steps we can take – on the part of the government, as well as in partnership with everyone else in the community. We have made some progress, and I will outline some of them, but I invite you to look at the report. We have made great steps but we can do more.
4 This year’s World Diabetes Day theme by Diabetes Singapore is “Advancement in Diabetes Care and Management”. We also want to look at the family because a diabetes patient does not just suffer alone. It is the whole of the society, in particular the family around the patient that we must also look out for, and the patient’s caregiver network is particularly important. What we want to do now is to shift the focus a little bit more to the person to take individual ownership of the problem and to look at the problem not just when you are down with diabetes, or what you can do upstream when you are still well to look after yourself, to screen more and so on.
5 When we look at it upstream before we develop diabetes, there are so many things we can take into our own hands and control ourselves, for example, healthier eating choices. We all love our makan in Singapore, but we can be a bit more discerning, a bit more selective and we can go for the healthier choices options which I have tried, even in the hawker centres and they are pretty good. We can keep physically active. We can look at the options we have here, the tracker system that everyone has. It is very popular, and I think it encourages Singaporeans to be out and about. We can go for regular screening to pick up early signs of diabetes early. Earlier detection just means earlier intervention and that significantly improves the prospects of being able to better manage the disease. Individuals can also live well with diabetes by participating in their own treatment plans, taking ownership of it, understanding what it means and then seeing it through together with their medical team. To drive this shift towards individual ownership, there are three areas that I want to elaborate this morning – (i) patient empowerment – what can we do for the patient, what can we do to empower the patient to take more individual ownership, (ii) how do we ensure that our healthcare professionalsas well as people in our community, people like you here – how do we better equip and give you tools so that you can help others as well in the community, and (iii) how do we enhance our ecosystem, our supportive environment, the food we eat, the lifestyle we lead and the choices we make in terms of treatments and screening.
PATIENT EMPOWERMENT
6 For patients to be empowered, there needs to be individualised goals. I think each diabetes patient is different, and I think we need to recognise that it is not a one-size-fits-all approach. We need to start to look at the patient profile, the state of the disease and also to curate the programmes for the patient’s care. The Ministry of Health (MOH), together with our healthcare partners and stakeholders, has been developing the National Diabetes Reference Materials (NDRM). As part of our Patient Empowerment for Self-care Framework, these materials can be used by both healthcare professionals during consultations as well as lay volunteers during visits to see patients. The first tranche of materials has been available on HealthHub since December 2018. For those of you who have not been on HealthHub to download the materials, please do so. It is very convenient, very accessible, a lot of information resides on that portal. We will now make that set of materials fully available in the four different languages. That will be done by the end of this year so no more excuses not to look at HealthHub and to look at the materials.
7 We are also developing a platform on HealthHub that will allow caregivers to download specific pages from the NDRM, and put together different subsets, curate them to customise them for their patients that they are looking after. This platform will be available from the first quarter of 2020.
8 We have started on the next phase to co-develop more in-depth materials in selected areas of diabetes care. To do that, we do not just sit and decide what kind of textbooks, what kind of materials to put up there. We want to work with people who are going through the disease, work with people who are caregivers. Between August and September this year, some 660 Singaporeans participated in six community pop-ups across the island to share their views on diabetes-related issues – what are the difficulties they face, how do we best give them some tools, readily accessible and available, to help them combat it. Fifty citizens came together, sat with us and our team to look at the selected topics that we want to develop more in depth. These materials were developed through what we call a Citizen Design process, to work with Singaporeans, to develop programmes for Singaporeans. We also will be inviting healthcare professionals and other stakeholders to give further input before we finally have the materials ready.
9 Our healthcare clusters are also working towards transforming the healthcare system to better empower patients. I think that has been the focus of many of our healthcare clusters, to give choices to patients. For instance, at the National University Health System (NUHS), through its Centre for Chronic Disease Prevention and Management, they have introduced programmes to motivate individuals, to curate customised programmes to motivate them so that there is greater involvement. If you design a programme that is available for all and it is not customised, it is very easy to fall out of the programme. But when you develop something that is meant for the patient, to help him or her chart that path, it is much easier to stay on that path. It is what NUHS has done. The programme was piloted in September 2017, and has since been extended to the National University Polyclinics last year.
10 Through this programme, patients like Mr Shekhar has been able to participate more closely, more actively and also I think more whole-heartedly in the programme. He was able to better reflect on how his lifestyle and work, what he does on a daily basis, what he eats, his own personal diets and personal conditions, and that in turn made his medical consults with his medical team, a lot more meaningful. It is specially curated for this patient. Based on this, he came up with his own management plan to increase his frequency of exercise in a sustainable and achievable manner. We do not say that everyone must run 10km a day. That is not achievable or realistic, but for some, we need to focus on a bit more on diet, others a bit more on exercises and lifestyle. It is different courses for different patients. More than 500 patients have enrolled in the programme as of October 2019. For Mr Shekhar, after being on the programme, he has better glycaemic control, which is crucial for diabetes patients, lost around four kilograms so far, and he continues to set higher and higher goals for himself.
EQUIPPING OUR HEALTHCARE PROFESSIONALS AND THE COMMUNITY
11 Besides empowering our patients, our healthcare professionals and volunteers in the community also need access to more training and resources. I think that is important. As we learn more about the diseases, we learn how to manage it, we must cascade this down to the community, to those caregivers so that people understand, people know who to implement, and people know what they are treating and why they are doing some things.
12 Singapore has a high rate of diabetes-related foot and leg amputation. Diabetic foot screening is crucial for early detection. The earlier we detect and intervene, the less likely it is that you will be facing diabetic foot amputation. One of the National Diabetic Foot Workgroup’s recommendations so far is a risk-stratified framework. It is not just one size fits all, but it is based on the risk associated with particular patient. A risk-stratified framework for foot screening, management and escalation to tertiary care at each stage, looking at the specific conditions of the patient very carefully. This is being progressively rolled out across our polyclinics and public hospitals, and will be extended to GPs in the next phase. MOH, in consultation with the Workgroup, will also be rolling out a public campaign to encourage persons with diabetes to have their feet checked at least once a year, and more frequently if they are found to be at higher risk of foot complications.
13 I want to touch on another topic that is very close to my heart, which is volunteers. Volunteers make our community programmes work. Without volunteers, we will not be able to do many of our programmes. To strengthen community support, there are initiatives to better equip the volunteers as well. We want volunteers to feel treasured and to be given information, and to be part of the process in working with us, working with the medical team to help to serve the patients better, Layperson volunteers known as Health Peers are trained by professionals to engage and support residents who are at risk or diagnosed with diabetes to live healthily. As of October 2019, we have more than 650 such volunteers, training, understanding the basic needs and also knowing how to deal with diabetic patients and knowing what signs to look out for. For example, Karen is a volunteer who has benefitted from the Health Peers training under NUHS. Not only does she feel more confident and empowered when she speaks to the care recipient, but it makes a difference to her own lifestyle. She then becomes a node of influence of the people who live and work around her.
ESTABLISHING A SUPPORTIVE ENVIRONMENT
14 Finally, let me know talk about the overall ecosystem and framework. To make healthier dining options more accessible, Health Promotion Board (HPB) has been strengthening its food strategy efforts, in terms of how we make our food more healthy, how we give more options, how we let people decide and know when they make certain purchases, what they are buying and what they are eating. That is also important, to give patients and their caregivers that power. You all know the Healthier Choice Symbol (HCS), and of course we have the Healthier Dining Programme (HDP), introduced in 2001 and 2014 respectively. We now have more than 3,500 HCS products available across 100 food categories and their sales have been growing. It is not just healthy food choice, but also quite tasty as well. That is why the sales has been growing annually at 9% every year. More partners are coming onboard. What we also want to do is to work with partners who matter in the community. For example, some of the best hawkers with the best dishes, even food like Nasi Briyani typically regarded as unhealthy as it is high in oil, we will work with them to make it palatable, and I think that is important. So 50% of the stalls across all hawker centres now have at least one healthier option on their menu. If you go to any hawker centre, one out of two hawker centre or coffeeshop, at least one item is a healthier choice option and slowly we will continue to cascade this across the island.
15 In June this year, we announced a ban on partially hydrogenated oils that will be introduced in 2021. Something that we feel quite strongly about as well, along with of course the sugar beverages that overall control lifestyle. We want to take a approach that is not trying to control everything that is being done, including what you eat, but we do need to look at what the outer margins are and try to have some control. Sugar and partially hydrogenated oils are something that we want to look at more closely. Several supermarkets and manufacturers recognised that the market out there is not going to be sustainable in the long term, and they have stepped forward and said they will work with us and comply by June 2020, one year ahead of schedule so I thank them very much. Without working with the community, without partners in our community, our measures would not be sustainable. Our more recent efforts to initiate healthier living choices among Singaporeans include measures to reduce sugar. We want to give options, give you information and nudge consumers to take the healthier choice.
16 The National Steps ChallengeTM is one of the best programme because it keeps you fit, it keeps you healthy and it plays on the one very typically Singaporeans sentiment – competition. 1.9 million sign-ups have occurred since the first installment of the National Steps ChallengeTM. It is a programme that has been successful and will continue to grow. I encourage you to also bring the people in your community to take part in the programme.
17 So those are three areas – how do we empower individuals, how do create an ecosystem that is conducive, and how do we make sure those who are caregivers and volunteers are better empowered – a three-pronged approach as we take the War on Diabetes further forward.
CLOSING
18 In closing, I want thank Dr Tan and the team. It is working with partners like this in the community, forums like this, occasions like this, with so many other food manufacturers, that makes this a worthwhile effort. It makes this a sustainable effort so I thank you very much for that and I hope that you would continue to further the pledge against the War on Diabetes, and ensure that Singaporeans are able to manage and control this disease. Let’s not just focus on those who are stricken with the disease, but let us go upstream, and make sure that for as long as possible, we remain out of the medical system. I wish all of you a very pleasant weekend. Thank you for being here. I hope you exchange information, exchange experiences as well, and share tips with each other. That is the purpose of coming together on a Sunday morning like this.