Prime Minister Lee Hsien Loong regarded the high diabetes prevalence amongst the Malay and Indian communities as a “health crisis” during the recent National Day Rally. This brought the worrisome state of the community’s health that has been troubling the healthcare community under the spotlight.

HOW TRUE IS THIS REFLECTION?
Diabetes is deemed as a global emergency which had worsened over the years before it eventually caught the attention of policymakers. In 2006, the United Nations Resolution on Diabetes had recognised the need to strengthen public and healthcare delivery systems as diabetes is a chronic and costly disease with severe complications. The International Diabetes Federation (IDF) has been observing 14 November as World Diabetes Day since 1991 in order to raise diabetes awareness.

According to IDF, 1 in 11 adults have diabetes with 1 person dying from diabetes every six seconds in 2015. One in seven pregnancies is affected by gestational diabetes where mother and child are at future risk of developing diabetes by as much as 50% and an eightfold increase respectively.

Unfortunately, Singapore has exceeded these international figures, second only to America amongst the developed nations. According to the local National Health Survey 2010, 11.3% of Singapore residents aged 18 to 69 years old have diabetes, 12.3% of males have diabetes, 16.6% of Malays, and 33.4% of those aged at least 60 years old have diabetes. A third of diabetes patients are unaware that they have the condition. Amongst those with diabetes, a third have poor control. Those with diabetes account for 2 in 5 strokes, 1 in 2 heart attacks and 2 in 3 kidney failure cases. The figures are startling.

As diabetes is asymptomatic until its advanced stage or when complications have arisen, health screening is necessary to detect this condition. However, only 54% of Malays undertake regular health screening for diabetes, the least amongst the ethnic groups, and are twice more likely to smoke.

HOW DOES DIABETES AFFECT ONE’S LIVELIHOOD?
Diabetes is diagnosed with an unexpectedly high glucose level, resulting in complications. It decreases immunity, impeding recovery from infections and affects bodily functions. Over time, there is gradual damage to blood vessels, with consequent nerve damage resulting in decreased sensation or increased pain and damage to essential organs.

Locally, majority have Type 2 Diabetes, which is contributed by non-modifiable factors like racial predisposition and age, and modifiable factors such as lifestyle, weight and smoking. Lifestyle changes such as having a healthy balanced diet, regular exercise of moderate intensity and substantial weight loss for those overweight reduce the risk of developing diabetes by almost half.

The National Nutritional Survey 2010 revealed that 6 in 10 adult Singaporeans consume higher than the recommended energy intake. Malays have the lowest intake of fibre amongst the ethnic groups, and overconsumption of fats and carbohydrates, which result in weight gain. Fibre reduces surges in sugar levels and encourages satiety, reducing weight gain.

ISSUES IN TACKLING DIABETES WORLDWIDE
Firstly, global healthcare had concentrated on treatment to prevent downstream complications, rather than prevention. Translating this to diabetes, most of the efforts, funding and policies had concentrated on life-sustaining measures by screening for and managing diabetes complications, to prevent blindness, end-stage kidney failure needing dialysis, and leg amputations. This increased lifespan but not the productive years.

Moreover, the attention and drive to develop the most suitable treatment for the sick, whilst pertinent, means the longer term need for prevention gets neglected. As a chronic disease which progresses over time, it is ideal to first prevent diabetes before it is too late.

Secondly, most research funding came from pharmaceutical companies. Hence, they were targeted for improving glucose levels and controlling cardiovascular comorbidities. Most funding had been concentrated in the West despite the evidence that the genetic make-up for different geographic regions are dissimilar, resulting in different disease presentations and hence, the need for a targeted approach. Funding and effort to tackle diabetes at its roots would need to come from well-meaning societies and philanthropists to be better directed.

Thirdly, even for disease control, newer treatment is out of reach to the majority. Those in the lower socio-economic groups are worse affected.

ISSUES IN TACKLING DIABETES IN SINGAPORE
There is now a social drive to change the mindset of the nation towards shifting healthcare to the community and encouraging self-empowerment. Within the healthcare sector, there is a drive towards integrating primary and secondary care, as well as public and private healthcare sectors to encourage all members of the healthcare community to contribute. Nonetheless, the blind spot remains. There are many layers of the society that have fallen through the gaps despite the available programmes, either due to the lack of awareness or rigid standard operating procedures on the ground. Programmes that do not have adequate follow-through are as good as having none.

Even more troubling is the poor integration between the different sectors for one’s health needs. The available social and financial support are not weaved in with medical support despite their interdependence. Finance for medical needs has been concentrated at hospitals, which is an expensive resource, and is better off being redistributed to support the community network. On the other hand, community organisations, having never played a major role in the healthcare network, need hand-holding and resources to start this new initiative right. However, reaching out to those in need is an uphill task due to the red tape on the sharing of medical conditions and social circumstances.

APPROACHES WORTH CONSIDERING
Currently, physical activity is largely removed from work or leisure, in view of the influence of technology in our lives. Additionally, more traditional meals are now prepared speedily without much thought into meal planning. Those in the non-healthcare industries, be it the religious organisations, community services or the education ministry, need to be committed to ensuring that the activities and diet are reflective of this urgent need. It is evident that changes are needed in the places where one spends most waking hours such as the childcare centres, schools, tertiary institutions and workplaces. Yet, time spent in them has escaped analysis.

A healthy mind results from a healthy body. A child who is happy, eats healthily, and engages in games or sports to keep active, is likely to supersede his contemporaries in performance, free from the influence of undue stress and mobile devices. In schools, curriculum and assessment can reflect this better. Shorter teaching periods and assessments with more experiential learning resulting in more time spent in health-promoting activities should be implemented.

At the workplace, physical activity should be incorporated in breaks of 15 to 30 minutes each morning and afternoon to recharge the mind and body. Staff gyms do not translate to a healthier workforce if no time is allocated to do physical activities. Logically, staff uniform should be replaced with sportswear except for front-liners during formal occasions. Health-promoting activities are as pertinent for staff as regular training sessions for cognitive stimulation as good health translates to happier employees with better productivity. Instead of multitasking using mobile devices and social media connections to increase productivity, adopting personal interactions through games and sports to improve relations between colleagues has additional health benefits. It takes a thoughtful leader to lead the way in the drive to a healthier workforce.

Community leaders need to lead by example through ensuring that regulations aid rather than impede the best patient care, and to use technology for improving access to the needed information. Likewise, the media has an important role in ensuring the right message is conveyed, sieving false information from rampant irresponsible advertising.

For the healthcare community, care collaboration without undue concerns of medico-legal implications will ensure the best patient care.

The need for adaptation in a nation with a high prevalence of diabetes is real. Concurrent with the drive towards a smart nation, employers need to find innovative ways to re-employ those affected by diabetes to contribute to the workforce through technology.

THE FUTURE
Research and development in diabetes care have been progressing by leaps and bounds. Yet, more effort needs to be devoted to the execution of diabetes prevention at the different life stages; from the married couple as future parents, as expectant couples, as neonates, as children, as teenagers and the working adults.

Whilst tackling diet and physical activity is only half the battle won, each of us can contribute in solving this issue. Instead of searching far and wide for solutions, we can start by being an ambassador in our own family and social circles. In fact, we can commence right now within our homes with exercise and breakfast to start the day each morning. Every one of us can surely do at least that much to initiate the change in our loved ones today. ⬛

Dr Sueziani Zainudin is a Consultant Endocrinologist at Sengkang Health. She heads the Muslim Healthcare Professionals Association (MHPA) Education chapter and serves on the Endocrinology committee in the Academy of Medicine Singapore. She is heavily involved in the war against diabetes through local and international organisations