SINGAPORE: Singapore’s War on Diabetes has captured the attention of a worldwide audience as, for the first time in history, a country declared a whole-of-government approach against a chronic disease.
It is easy to assume the Ministry of Health will be leading the charge in this war, for they hold the mandate on health promotion and screening, as well as on the management of diabetes and its complications.
However, there is a good reason why Prime Minister Lee Hsien Loong announced during the last National Day Rally speech that the whole country needs to come together if we are to win this war.
Many people do not realise that health problems are often the leading indicators that something upstream is very wrong – whether it is our lifestyle and habits, or whether it is the environment that we are exposed to.
For example, chronic diseases such as diabetes and high blood pressure require years of exposure to a lifestyle of imbalanced nutrition with low levels of physical activity. A mass outbreak of dysentery points to a poorly managed and unclean food and water system. The rampant spread of malaria or dengue infections suggest a gap in vector control policies to curb mosquito breeding.
When it comes to promoting and maintaining health, the discourse has often been split between the role of government versus that of individual responsibility. Governments that play an enthusiastic role in protecting the health of citizens with legislation, be it around tobacco or sugar, are often criticised for curbing civil liberties.
But at the same time, will ordinary citizens make the right choices if they are left to their own devices?
CONSUMPTION CHOICES A RESULT OF CAMPAIGNS
What many do not realise, is that what we perceive as our own choices, are often the results of carefully studied, researched and engineered campaigns by people who design the living environment around us.
Take for example the food environment planned by retailers and manufacturers. There is a wealth of literature discussing the psychology of the average consumer in a supermarket, and products are researched and strategically placed with the specific intent to maximise sales.
Many countries have laws on advertising bans and curfews of unhealthy food products high in sugar, fat and salt. Yet, we allow supermarkets to subconsciously and insidiously influence our shopping patterns by strategically placing these products at eye level, end of aisles, or next to the check-out counters, often with eye-catching promotional discounts aimed at maximising sales.
The food and beverage (F&B) industry conduct multiple tests with panels of remunerated subjects in order to identify the “sweet spot” in taste and colour – the perfect combination of sugar, salt and other ingredients that maximises acceptance and desire, and correspondingly consumption and sales.
The implicit incentives with the “up-size” mentality, where portion sizes are increased for a disproportionately small increase in price, also serve to seduce one into consuming beyond typical dietary requirements.
This is why the battle against the excessive consumption of nutrient-poor, high-caloric food cannot overlook the role retailers and the F&B industry play.
Regulation is one way to compel these industry players to behave more responsibly, but another approach is to engage the same marketing and food science experts to design healthy yet tasty versions of mass-consumed food items such as noodles and rice – exactly the approach adopted by Singapore’s Health Promotion Board.
LIFESTYLE AND PHYSICAL ACTIVITIES SHAPED BY ENVIRONMENT
Often, the environment provides opportunities and constraints that encourage and incentivise particular behaviours. Studies of product placement in vending machines have shown that people tend to choose healthier options or even water, when informed of the amount of sugar and calories present in the available choices.
And yet, the opposite appears to be true as well. It was recently reported that when restaurants charge for plain water, consumers are nudged towards purchasing sweetened beverages.
Think also about fast-food restaurants where changing the bundled soft drinks to bottled water incurs an additional surcharge.
It is not solely the food environment that we are up against. Modern architectural and urban planning designs have resulted in a physical environment that promotes accessibility and convenience, which in turn has reduced incidental physical activity.
The more interconnected our transportation networks are, the lesser we walk and stair-climb between the home and the workplace. It is ironic that these days we need new-fangled appliances such as physical activity trackers and mobile phone applications to remind and nudge us to do something basic such as walking and stair-climbing.
WHY ARCHITECTS AND SOCIAL SCIENTISTS MUST BE INVOLVED
The design of the urban environment also exerts a powerful influence over the amount of physical activity engaged by the masses in a daily manner. Do the stairwells in buildings encourage the inhabitants to take the stairs, especially when moving between consecutive levels?
Are the walkways between transportation hubs to residential estates sufficiently broad, covered and airy to promote walking? Are the park connector networks extensive and connected enough to encourage part of the workforce to cycle to their workplaces?
In fact, the World Health Organisation launched the Healthy Cities Movement in the 1980s to explicitly recognise the importance of urban planning, where developing the built environment landscape through the placements of transportation hubs, food centres and recreation zones, collectively have a sustained impact to promote health-seeking behaviors.
Environmental nudges may be subtle, but they are also ubiquitous and enable persistent modifications to our lifestyles. The F&B industry has been quick to capitalise on the covert role that psychologists, sociologists and marketing consultants play in influencing spending patterns.
At the same time, urban planners and architects are beginning to realise the impact their designs have on human health. It is time that these multi-disciplinary experts are properly recognised and reminded of their roles in encouraging health-seeking behaviours.
After all, while physicians may hold the key to treating people with diabetes, the key to preventing diabetes in the first place may just lie with social scientists and architects.
Dr Teo Yik Ying is dean of the Saw Swee Hock School of Public Health at the National University of Singapore.