New Strategic Framework to Empower Clinical Management of Diabetic Foot Complications

            As part of Singapore’s efforts to enhance the management of diabetes, the National Diabetic Foot Workgroup has developed a national strategy to reduce amputations of the leg/ foot, also referred to as lower extremity amputations (LEAs), among patients with diabetes. The Workgroup, comprising specialists, primary care doctors, nurses and podiatrists, was established by the Ministry of Health (MOH) in April 2018 as part of the War on Diabetes.

2.          Diabetes is the most common cause of non-traumatic LEAs in Singapore. In 2016, nine in 10 Singapore residents aged 18 to 69 years, who had an LEA, had co-existing diabetes. Singapore also has one of the highest diabetes-related LEA rates in the world, with about 180 LEAs performed in 2015 for every 100,000 adult Singaporeans with diabetes, as compared to the Organisation for Economic Co-operation and Development’s (OECD) average of 60.

3.          To curb this trend, early detection as well as timely and comprehensive clinical management for patients with diabetic foot complications is crucial. The national strategy encompasses the following key thrusts:

Establish a national risk-stratified diabetic foot screening and management framework across primary and acute care, including patient segmentation and guidelines for foot screening and management;Enhance patient empowerment with more targeted education during foot screening, as well as the development of diabetes foot care materials under the Patient Empowerment for Self-care Framework; andAttract, train and retain skilled manpower, e.g. podiatrists, podiatry assistants and foot care nurses, through their upskilling and optimisation of deployment across primary and acute care, with greater emphasis in the community.

4.          A set of clinical guidance will guide healthcare professionals – in particular, primary care doctors and nurses – in performing regular, comprehensive foot assessments for patients with diabetes, so as to identify and treat diabetic complications in a timely manner. It will be published by April 2019.  Updates on the War on Diabetes: Healthy Living
Healthy Eating

5.          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, such as the Healthier Dining Programme (HDP) to increase the availability and accessibility of healthier food and beverages. As of mid-October 2018, more than 1,200 food and beverage (F&B) operators, hawker centres and coffee shops, with 8,900 touchpoints and stalls islandwide have joined the HDP, offering at least one healthier option in their menu. The number of healthier meals sold under the HDP doubled to 50 million in FY17, from 26 million in FY16. 

6.          In May 2018, the Whole-of-Government Healthier Drinks policy came into effect to make healthier, lower-sugar drinks the default in government premises. All pre-packaged beverages sold on government premises have to meet the Healthier Choice Symbol (HCS) lower-in-sugar guidelines, while freshly prepared coffee and tea should be served with no added sugar. As of August 2018, more than 90 per cent of agencies have implemented the policy.  Exercise

7.          Encouraging more Singaporeans to exercise regularly is a key strategy in the fight against diabetes. HPB offers a wide range of physical activity programmes across the island to cater to different segments of Singaporeans of varying fitness levels including working adults, families and seniors. Some initiatives introduced by HPB include the nation-wide National Steps Challenge™, which has garnered over 1 million sign-ups across the past three seasons.  

8.          The Healthy Preschool Framework was introduced in 2015 to help accredit preschools that have comprehensive school health promotion practices for students, parents and staff. As part of HPB’s Healthy Pre-school Framework, HPB works closely with pre-schools to ensure that physical activities are incorporated into their daily timetable and lesson plans. As of 31 October 2018, 1,075 preschools in Singapore have been accredited as a Healthy Preschool. Of which, 73 per cent of accredited preschools are on the Platinum Tier and are certified under HPB’s Healthy Meals in Preschools Programme. Updates on the War on Diabetes: Early Detection and Intervention 9.          Regular screening is also one of the key strategies to help Singaporeans take charge of their health and improve early detection of pre-diabetes or Type 2 diabetes. We have made it easier and more affordable for Singaporeans to go for regular health screenings, with enhanced government subsidies from 1 September 2017 under the Screen for Life (SFL) programme. As of end October 2018, around 60,000 Singaporeans have benefitted from the enhanced SFL screening subsidies.

10.          Besides older adults, youth and young adults can also be susceptible to the onset of diabetes. To identify and channel these individuals who may be at higher risk of diabetes to diabetes screening, the Diabetes Risk Assessment (DRA) tool was launched on 1 September 2017 to encourage adults aged 18 to 39 years to assess their current risk for diabetes. As of end October 2018, the DRA tool has been used about 230,000 times by individuals aged 18 to 39 years, of which about 16.5 per cent of responses were assessed to have met the criteria for having a higher risk of developing diabetes. 

11.          HPB also collaborates with healthcare institutions, employers, businesses and unions to encourage more Singaporeans to go for regular health screenings. Within the community, healthcare institutions conduct community health screening programmes, while patients are encouraged to attend health screenings when they visit the polyclinics and general practitioners. In the workplace, HPB has also introduced basic health screening and health coaching to mature workers in seven priority sectors¹ to help them build skills on chronic disease management (including diabetes) and manage occupational health concerns.

12.          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 2018

¹The seven priority sectors are transport and logistics, retail, cleaning, security, food and beverage, education, and healthcare.