Research on behaviour, targeted messaging may help Singapore's war on diabetes: Experts

Research on behaviour, targeted messaging may help Singapore's war on diabetes: Experts

Diabetes patient
A patient with diabetes monitors his blood glucose with a glucometer at a public hospital on Sep 2011. (Photo: AFP/Elmer Martinez)

SINGAPORE: With many countries facing the challenge of rising levels of diabetes, developing different strategies to target specific sectors of the population is emerging as an effective weapon.

In Tower Hamlets, a borough of London, minority ethnic groups make up more than half the population. A majority are Bangladeshi immigrants.

“Tower Hamlets was the worst performing region in the entire UK in terms of diabetes prevention and care,” said Prof Tai E Shyong, a senior consultant at the National University Hospital's Endocrinology Division who has looked at overseas strategies which might work in Singapore. 

When a diabetes programme was established in Tower Hamlets in 2007 to communicate the risk of diabetes, encourage residents to make lifestyle changes and educate them about medication, healthcare providers roped in the community. 

They trained people as advocates to help patients interpret medical results, communicate patients' concerns to health providers and participate in the care planning, which Prof Tai highlighted as an effective strategy.

Religious leaders of the mainly Muslim community were also consulted, and proved invaluable working with healthcare professionals when it came to advising residents on dietary and lifestyle practices.

In 2014, studies showed that Tower Hamlets had among the best general practice results in the UK. People had better control of the disease, blood pressure and cholesterol levels were under control and fewer people with diabetes were being admitted to hospital.

Tower Hamlets
Tower Hamlets, a borough in the east of London, had among the worst diabetes care rates until it started a programme with the community. (Photo: Greater London Authority)


Around 10,000 kilometres away, Singapore has been trying a similar approach. More than a year after the Government declared a war on diabetes, Prime Minister Lee Hsien Loong once again refocused the national gaze on the disease at the National Day Rally earlier this month, calling it “a crisis” in the Malay and Indian communities.

Half of Malays and 60 per cent of Indians over the age of 60 have diabetes. To tackle this, a number of organisations have been reaching out to these communities. For instance, the People’s Association’s Malay Activity Executive Committees Council (MESRA) has held more than 50 health fiestas and carnivals.

The Council’s chairman Omar Ismail said activities have included health screenings for Malay residents who attend the events, most of whom are between the ages of 50 and 70. 

“After their screening, when they receive their results, we will work with them to explain the results, like how to control their food intake, how to be more active, taking less sugar and so on.”

The Health Promotion Board (HPB) is among MESRA’s collaborators. Dr Shyamala Thilagaratnam, HPB’s Director for Regional Health and Community Outreach Division, said her organisation has also started working with mosques and temples.

During Ramadan this year, it launched a recipe book with healthier replacements for traditional Malay food. It also organised a cooking demonstration in which congregants were taught to cook traditional Lontong with brown rice instead.

“This year, we’re also implementing a new programme at mosques called ‘Jaga Kesihatan, Jaga Ummah’, which means, look after your health, look after your congregants,” she said.

“So far, we’ve had five mosques coming on board as a start. The programmes started in August and will include regular physical activity programmes, cooking demonstrations, screenings and health talks.”

Dr Shyamala said response has been “heartening”, with one mosque sending its canteen operators for training in cooking healthier meals.

For a group of Singaporeans such as the elderly, Prof Tai said having culturally specific programmes may indeed be useful when tackling diabetes. 

“They are people, particularly those with chronic disease, who are now in their 60s. They’ve maintained a different lifestyle and different culture, their social circles are different. The channels through which we can influence their choices and where they get their information from are also different.” 


However, one expert suggested that there is no need to broach the topic from a perspective of cultural difference. This is despite the perception among some people that Malay and Indian food can be particularly unhealthy. 

“Yes, Malays and Indians are at a slightly higher risk compared to the Chinese,” said Prof Chia Kee Seng, dean of the Saw Swee Hock School of Public Policy.

For example, Prof Chia said the risk for diabetes is very high among the Chinese if their BMI is above 27.5. Among Malays, the high risk threshold is between 26 and 27, while among Indians, the risk is very high at a BMI of 25.5.

“So many would attribute this to genetic differences.. but I think we must bear in mind that in terms of lifestyle, we’re becoming more and more homogenous as a society - the Chinese eat Malay food, for example.”

Prof Chia said while the overall diabetes risk for Chinese is 10 per cent and for Malays and Indians it is about 15 per cent, he thinks the gap in diabetes rates between the races will narrow in future.

“The main driver of diabetes is lifestyle. Yes, the genetic factors are like the soil, but the lifestyle is your water and sunshine. You may have the seed in the right soil, but if you don’t have water and sunshine, it’s not going to grow.

“Genetically you may be at a slightly higher risk, but if you don’t have a bad lifestyle nothing happens. So we are not predestined by our genes. We are actually modified by our lifestyle.”

Instead, Prof Chia said the conversation needs to move towards understanding behavioural differences when it comes to prevention and treatment.  


The rates for attending health screenings and subsequent follow-ups among the races are also worth looking at, said Prof Chia. As an example, Mr Omar said among the 26,000 mostly Malay residents who attend MESRA’s health events, 10 per cent go for screenings.

So while Singapore has done a great deal of research into understanding diabetes across the different ethnic groups, understanding what makes the different communities tick when it comes to taking control of their health needs more research, said Prof Tai.

“I think that’s the piece we have fallen down on. We’ve relied largely on financial incentives, on frightening people about the complications of diabetes, if that was going to work, it would have worked by now,” Prof Tai said.

With an urgent national focus on tackling diabetes, Prof Chia added that more focus is needed on crafting the information that is disseminated, to ensure the public is interpreting information accurately. 

Source: CNA/mo