Speech By Dr Janil Puthucheary, Senior Minister Of State, Ministry Of Health And Ministry Of Communications And Information, At The Asia Pacific Maternal And Child Metabolic Health Conference And IPRAMHO International Meeting 2021, 8 Jan 2021

Professor Alex Sia, CEO of KK Women’s and Children’s Hospital (KKH)

Associate Professor Ng Kee Chong, Chairman Medical Board of KKH 

Distinguished Guests

Ladies and Gentlemen

Good afternoon.

1.      It is my pleasure to join you today at the Asia Pacific Maternal and Child Metabolic Health Conference and Integrated Platform for Research in Advancing Metabolic Health Outcomes of Women and Children International Meeting or IPRAMHO in short. I am heartened to see that although we are still in the midst of the pandemic, this year’s event draws on a very strong pool of expert speakers, both locally and across Asia Pacific. 

2.      There are three key points I would like to cover: 

a. Firstly, we have made good progress over the years in improving the health and lives of Singaporeans, but as we have done so, increasingly, we realise there is much more to be done.

b. Secondly, in order to get those things done, we have moved increasingly upstream, to intervene and nudge behaviors early in the lives of children, mothers, and women yet to become mothers. 

c. Thirdly, in order to do this, there is no other way except increasing collaboration and partnership amongst practitioners, researchers, service providers, government and various agencies and industry partners is key for us to collectively identify the gaps and take steps to make meaningful impact. 

Progress on maternal and child health

3.      We have made good progress in maternal and child health over the past few decades. Based on the Global Burden of Disease 2019 study, Singapore ranked highly, in this particular study, first globally for life expectancy and health-adjusted life expectancy (HALE) at birth. Our infant and maternal mortality rates were 1.7 per 1,000 live-births and 3 per 100,000 live and still-births respectively in 2019, amongst the lowest in the world. 

4.      But there is room for improvement. Based on the National Population Health Survey (NPHS) 2019, self-reported diabetes has increased from 4.9% in 2007 to 6.9% in 2019 while self-reported hypertension and hyperlipidemia are all going up, as we have improved health outcomes in terms of mortality, obstetrics, paediatrics and in diseases of infection and middle age. The diseases of prosperity and the diseases of longevity have increasingly become our burden and our challenge.

5.      According to the Global Burden of Disease 2019 report, 35% of the Disability-adjusted life year (DALY) burden in Singapore can be reduced potentially by early intervention on known modifiable risk factors including smoking, poor diet, low physical activity, high blood pressure, high fasting plasma glucose level, high body-mass-index and high low-density lipoprotein level.   

Moving upstream to improving maternal and child health

6.      We have made a lot of progress, and that progress has now revealed new challenges and new frontiers that we must work on. Increasingly, the science demonstrates that the interventions needed in those new frontiers are known and modifiable to us. They are not particularly strange and uncertain, but getting this done can be difficult, because many of these modifiable risk factors must be tackled further upstream by improving child and maternal health. This has been demonstrated internationally and validated locally through studies such as, the Growing Up in Singapore Towards Better Outcomes (GUSTO) study – which KKH and NUH have collaborated – demonstrating these same factors in our local Singaporean population. The study observed that children whose mother was overweight prior to pregnancy had the highest probability of childhood obesity at 11.8%. Based on data from the Ministry of Education, the proportion of overweight children in our mainstream schools, aged 6 to 18 years, has increased, putting more of them at risk of future health issues such as diabetes in adulthood. We can do more to improve the lifestyle habits of our children and adolescents to reduce this.

7.      The findings from GUSTO, from the science that brought about this line of investigation is quite remarkable. Going back in human history, the idea that a healthy family and a healthy mother begets a healthy child is well known. You will see this in literature. It is an old wives’ tale, it is well understood common wisdom. But the science of how that works, has taken decades, if not centuries to slowly unravel. It is a remarkable story that brings together many strands of medicine, science, epigenetics, nutrition, the hormonal exposure, this whole the extent to which nurture influences nature, it's quite possibly one of those slow burn stories that will, if we get it right, potentially transform the health of generations to come. It is an exciting space. 

8.      But for all that big picture excitement and ability to draw together all the academic interest, you still have to get things done on an individual family basis, on an individual child, and modify those risk factors for an individual patient. One of the most important individual modifiable risk factors is physical activity.

9.      Our studies have reported, that more than one-third of children and adolescents in Singapore do not meet the recommended level of physical activity and this clearly is something that we can't have.

10.      We have been stepping up our preventive health efforts to encourage children to lead healthier lifestyles. 

a. We have provided pre-school children with well-balanced meals and encourage healthier eating. HPB introduced the Healthy Meals in Pre-Schools Programme, and currently we have more than 1,300 pre-schools on board. Pre-schools are also required to set a designated amount of time for outdoor activities to promote physical activity.

b. In the mainstream primary and secondary schools, students are taught good eating habits and the importance of regular participation in physical activity. This is an intrinsic part of the Physical Education curriculum. If they are outside the healthy range for physical growth are also provided support through targeted behavioral modifications for weight maintenance, as well as medical assessment and lifestyle counselling.

c. The Early Childhood Development Agency (ECDA) has also introduced the kidSTART programme, of which KKH is a partner. This programme assists children from low-income families by supporting parents with child development through imparting knowledge about growth, health and nutrition. Importantly, it also monitors the children’s developmental progress from birth till six years old, so that there is coordination for support and intervention for the family as a whole.

11.      We are also encouraging adults to keep themselves in good health through promoting better diet and exercise. HPB has been leveraging technology and behavioural insights to encourage Singaporeans to make positive lifestyle changes through several programmes such as the Eat, Drink, Shop Healthy Challenge, National Steps Challenge and islandwide workout programmes. We do indeed need to put in place many different programmes because there is no easy solution to this. The nudges and interventions have to fit within people's social and busy lives, and slowly bring them along this journey so that they themselves decide this is something they want to do. 

12.      It is starting to pay off. In our National Population Health Survey, we see that more Singapore residents have engaged in regular leisure-time physical activity, with about 1 in 3 (35.2%) engaging in regular exercise during their leisure time in 2019, an increase from about 29% in 2017. We have to continue. It will be slow progress, but we must keep persisting. Recently, HPB launched LumiHealth, a personalised health programme developed in collaboration with Apple to nudge Singaporeans and residents to adopt healthy habits through personalised reminders, programmes, activity coaching, and incentives.

13.      Another programme, Screen for Life, encourages individuals to go for regular health screening because we have to not look just upstream, but also downstream where there are consequences and problems for an individual patient we should look out for, pick them up early and provide them with the correct intervention and support. 

14.      These are just a broad description of the many key efforts so far. Now that we know so much about the mechanisms that drive the health of the adults, the mechanisms of how foetal life determines the health of the child, and how the health of the woman determines the health of the baby long before she becomes pregnant, we need to do something with this knowledge to improve the health of our patients, community and the next generation. MOH is looking at more programmes and ways to push further upstream with these interventions on the assumption that what we are doing currently is not enough, and there is new knowledge that is coming in about these issues. The research and programmes such as the ones that have been described, has provided us some confidence and clarity that we can do more by pushing upstream and that we will get beneficial results for the next generation if we do so. These are things that we are studying closely, and we will look to do more.

Collaboration is key to improve maternal and child outcomes

15.      Conferences, such as the one today, are an important part of how we need to decide on what to do, bringing together like-minded individuals, academic and practitioners across borders, domains and disciplines. This creates opportunities for new research ideas and collaborations, informing policymakers and industry partners to introduce new interventions or modify existing ones, overall, improving processes as well as the outcomes of maternal and child health.  that align with the development in the maternal and child health domain. We need to do this collectively to ensure that our children grow up well and healthy, and that pregnant women and mothers are in good health to enhance the child’s development, and the family as a whole,

Closing

16.      I would like to thank KKH and all participating institutions for your continued efforts to uphold healthier living in Singapore – all the work that you have done before, as well as getting us to this point where, in the midst of a crisis, we are studying how to improve maternal and child health for the next generation and bringing academic efforts together with the clinical evidence and governance across borders. Thank you very much.

17.      I wish you a successful and meaningful conference, and that you will benefit from the opportunity to network and exchange ideas with your counterparts in many different research, medical and academic insights.

18.      Thank you.