The Singapore Diet Reset
Professor Roger Foo, Lead Principal Investigator of Project RESET
Esteemed Colleagues, Distinguished guests, Ladies and gentlemen
I am happy to join you at the launch of Project RESET this morning. First of all, let me say something about this research project. It is a very significant project because heart disease continues to be a pressing health challenge and remains a top cause of death in Singapore and worldwide. In Singapore, on average every day, 34 people have heart attacks and 23 people die from heart disease.
2. Our healthcare system fortunately delivers very good clinical care to patients with heart disease. But we know this is not enough to tackle the challenge. We need to move upstream – scientifically, to invest in research, and socially, to shape lifestyles. Let me start with research, which is why we are here today.
Warning Against the Silent Killer
3. Over the past seven years, the MOH National Medical Research Council (NMRC) has provided about $180 million of research funding to support cardiovascular-related research. The funding goes towards many useful projects, including Project RESET, a large-scale collaborative initiative led by Professor Roger Foo and his team at the Cardiovascular-Metabolic Disease Translational Research Programme.
4. As we know, heart disease is a notorious silent killer. The arteries supplying blood to our hearts can clog up quietly and slowly, unbeknownst to us, due to factors such as unhealthy food intake, lack of physical activity and also our genetic pre-disposition. Project RESET aims to detect early signs of heart disease by identifying cardio-liver-metabolic biomarkers present in individuals who have heart disease but are still asymptomatic. Hopefully with these findings, we can unmuzzle this silent killer.
5. More than 10,000 Singaporeans will be invited to participate in Project RESET. The programme will capture a variety of data points – from genetic variations, clinical data to lifestyle information. This will provide a full diagnostic profile for each individual. Researchers then leverage Artificial Intelligence to analyse the data and identify the early warnings. I look forward to the day when the findings of Project RESET can translate into meaningful clinical interventions, for us to better manage heart disease.
We are Not Winning the Lifestyle Battle
6. The other important upstream aspect is our lifestyle which is what I am going to focus on today. With the right lifestyles, we can significantly reduce the risk of heart and other chronic diseases. Prevention is always better than cure and we need to have the discipline to invest resources and effort in this area.
7. As of now, we are not winning the battle on lifestyles. This is evident from the findings of two most recent surveys conducted by MOH, namely the annual National Population Health Survey and National Nutrition Survey. MOH will be releasing the results shortly, but here are some top line indicators which do not look good. Let me start with the National Population Health Survey.
8. The slightly better news is that our prevalence of diabetes is about one in twelve Singapore residents, and this has come down slightly over the past few years. This may be partly due to our efforts in the War on Diabetes, and people are more conscious about sugar consumption. Nevertheless, on average, every day, six people are diagnosed with kidney failure and require dialysis. We know sugar intake is a major cause of diabetes. We cannot become complacent in our War on Diabetes.
9. Next, about one-third of Singapore residents today have high blood cholesterol. The prevalence rate has been stable over the past few years, but this is a worryingly high number.
10. But the worst news is this. More than one-thIrd of Singapore residents now have hypertension. This proportion has nearly doubled from 2010. Hypertension and high blood cholesterol are both significant contributors to heart disease and stroke.
11. The explanation for the alarming rise in prevalence rate of hypertension is revealed in the National Nutrition Survey 2022. Chronic diseases like diabetes, hypertension and high blood cholesterol are consequences of our lifestyles, especially eating habits. We are what we eat. Food can be medicine if we eat well but it can be poison if we do not. A wise doctor once told me, “Live well, eat well, there is no need for medicine. Don’t live well, don’t eat well, and medicine is what we need to eat.” So we are what we eat.
12. The survey findings showed that our calorie intake has increased, with more individuals exceeding their daily recommended intake. We are also consuming more fat. But what is most concerning is that we are consuming a lot more sodium, found in common salt, soy sauces and other sauces. Excessive consumption of sodium is a direct cause of hypertension. Nine in 10 Singapore residents are exceeding their daily recommended sodium limit. In fact, on average, we are consuming about twice the daily limit.
13. We need to make personal lifestyle changes to turn the situation around, otherwise we are killing ourselves. This requires a joint effort, of the Government making policy changes, communities and doctors supporting residents, but most importantly individuals taking personal action to change lifestyles and habits.
Shifting our Dietary Habits
14. MOH, through the Health Promotion Board, will therefore make a bigger push to change our dietary habits.
15. I want to assure everyone that we will do so without making our food bland and uninteresting and without depriving people of their favorite past time of eating or undermining the diversity and colour of the Singapore food scene. We can do both and achieve both at the same time. In fact, if done well and appropriately, our efforts can achieve the opposite, which is to enhance our enjoyment of local food, while making our diet healthier. Let me explain how this can be done.
16. Take for example, HPB introduced the Healthier Choice Symbol and Healthier Dining Programme identifiers which help us make better food choices when we shop in supermarkets, for example. Today, the Symbol covers a third of the market share of packaged food products. This is about 4,000 products in 100 food categories. As consumers, many of us have become more conscious of making healthier choices when we go grocery shopping. This initiative did not make our food any less enjoyable. It just made it healthier.
17. We can do more to manage excessive consumption of the two most common nutrients that cause the most health problems – sugar and salt that contains sodium – which cause diabetes and hypertension respectively.
A New ‘Siew Dai’ Default
18. Let me start with sugar. Most of our sugar intake comes from packet or canned drinks, or what we call pre-packaged beverages. We have therefore introduced Nutri-Grade labels to help consumers identify pre-packaged beverages that are higher in sugar and saturated fat.
19. The initiative has been very effective. Since the announcement of the measures in 2020, companies have been reformulating their products by reducing the sugar content. The median sugar level of pre-packaged Nutri-Grade beverages has reduced from 7.1% in 2017 to 4.6% in 2021. Close to two-thirds of pre-packaged beverages in the market are now graded “A” or “B”. The latest results from the National Nutrition Survey show that our total sugar intake has reduced by one teaspoon per person per day, from 60g/day in 2018 to 56g/day in 2022, which is not bad. It is reflected in the health survey as the prevalence of diabetes is steady and coming down a little bit, although more can be done.
20. We have announced that by the end of this year, we will extend Nutri-Grade labels to freshly prepared beverages. Outlets like coffee shops and bubble tea stalls are required to include the Nutri-Grade labels on displayed menus. Small stalls are exempted from this requirement.
21. The new measures will likely have a strong salutary effect. It will raise awareness of the harm of excessive sugar consumption, and just as manufacturers of pre-packaged beverages reformulated their drinks in anticipation of the change in policy, we hope many drinks outlets that prepare fresh beverages will reduce the sweetness of their drinks when the requirement comes into force at the end of this year.
22. If that happens, this presents us with a rare opportunity to reset the norm across the industry. Let me explain what resetting the norm means. Today, if we want less sugar in our beverages, we have to order a ‘kopi siew dai’, or ‘teh siew dai’. We should make ‘siew dai’ the new norm and default. That means if we order ‘kopi’ or ‘teh’ in the future they are automatically ‘siew dai’. If you want more sugar, you have to order ‘kopi ga dai’ or ‘teh ga dai’. If you want even less sugar, you might as well order ‘kosong’.
23. This is however a matter of consumer habits and choice, and not something MOH can regulate. What HPB will do is to launch an outreach and publicity campaign amongst industry players, hawkers and coffeeshops, to try to make ‘siew dai’ the new norm. I hope the industry, coffee shops and hawkers will support this initiative when we implement it towards the end of this year. Put the sugar at your stall, and if somebody wants to add sugar, let them add. But serve it with less sugar as a default.
Less Salt for More Taste
24. The next problematic nutrient is sodium, which is found in common salt. The majority of our sodium intake is from eating out. Hence last year, we launched a sodium reduction strategy, by encouraging suppliers for salt and sauces to replace regular salt with lower-sodium alternatives, such as potassium-enriched salt.
25. The results so far have been quite encouraging. To date, three major suppliers, accounting for close to half of the food and beverage salt market share, are now supplying lower-sodium salt. More than 350 hawkers, coffeeshop and food court stalls island-wide, as well as close to 150 caterers, are already using lower sodium ingredients.
26. Our efforts have given rise to some concerns. First, lower-sodium salt is a lot more expensive than regular sodium salt. With HPB’s industry grant support, suppliers have lowered the price of lower-sodium salt from $10 per kilogram to about $4 per kilogram. However, this is still four times more expensive than the price of regular sodium salt, at $1 per kilogram.
27. But given that a typical household uses about a kilogram of salt a year, the additional spending of converting to lower-sodium salt is about $3 a year. For $3 more a year, we can significantly lower the risk of hypertension, heart attack and stroke so I hope more households will consider this, I think it is a worthwhile spending.
28. Second, some members of the public with chronic kidney disease have also raised the concern that lower sodium salt, specifically potassium-enriched salt, can harm them. MOH took this feedback very seriously, and we have been consulting our medical experts on this matter.
29. Our clinicians and professional bodies have advised that these salt alternatives are safe for individuals with early-stage chronic kidney disease. As for individuals with late-stage chronic kidney disease, they should limit consumption of all forms of salt, whether it is regular salt or potassium-enriched salt. I understand that the clinicians and professional bodies are planning to issue this as a formal written advice.
30. We should consider other measures to reduce sodium content in our food through regulatory measures. We have studied how other countries have done this.
31. One example is Chile, which has implemented food labelling rules similar to our Nutri-Grade label. Hence, products exceeding the stipulated sodium threshold must have a "higher in sodium" warning label. This is very similar to what we did for sugar but they did it for salt. Finland, on the other hand, regulates sodium limits for selected packaged food items that are the main contributors of sodium in their day to day diet.
32. Both measures have worked. They have spurred industry reformulation and reduced their populations’ sodium intake. We will draw lessons from these examples, to consider what would be suitable to implement in our local context.
33. In the meantime, we still have to do something and we will embark on a no regrets move, to call on our industry to reduce the use of sodium in all our dishes. HPB’s market study shows that between 2010 and 2023, the sodium content of dishes in Singapore has gone up by an average of 20%.
34. This means that the same plate of Char Kway Teow or same bowl of Mee Rebus or Mee Soto we eat at the hawker centre today, has around 20% more sodium compared to 13 years ago. Somehow, over the years, our cooks and hawkers are adding more salt and sauces to our dishes.
35. HPB will therefore also launch a campaign to encourage industry and F&B operators to pledge to reset sodium levels, and roll back sodium content in their dishes to the levels in 2010. Cook like how you used to cook in 2010. They can do this by switching to lower sodium salt, or better, by adding less salt, or condiments like soya sauce and fish sauce in your dishes. HPB has done some initial outreach and has received quite good support from leading market players to commit to reducing sodium in their dishes and go back to their 2010 recipes.
36. Some may raise the concern that with less salt and soya sauce, our food will not taste good. Some may even point out that ingredients are getting more expensive, so sauces with high sodium are used as a lower cost substitute.
37. This may be true for some dishes. But it is also likely that having eaten more salty dishes over the years, our taste buds have gotten used to it, and equate saltiness with tastiness. We need to try to roll back our taste buds as well.
38. Having said that, I believe that many of our dishes, such as curries, chicken rice, nasi lemak, fried carrot cake etc, because of the way they are cooked, they can be equally tasty without the extra salt. In my conversations with many diners at hawker centers, especially amongst those who cook a lot at home, many in fact told me that the food would taste better without the extra salt and soya sauce.
39. We must remember that Southeast Asia, we are the land of spices. We use a great variety of spices and ingredients in our food, and we use a wide range of meats, seafoods, vegetables and fruits in our local dishes. All of them add natural flavours to our food.
40. Hence, in our multicultural society, whether you are Eurasian, Indian, Malay or Chinese, our food is naturally flavourful. We do not need so much salt to enhance the taste of our cuisines. Conversely, we mask flavours and under-appreciate our food when we add too much salt, soya sauce and belachan to our food. In Singapore and Southeast Asia, less salt always can mean more taste.
41. So I hope that the F&B industry would respond positively to our ‘less salt is more taste’ campaign. Diners, we can do our part too. We can ask to have a less salty dish. And if after eating a dish we find it too salty, we can politely tell the chef or the hawker, and over time they will adjust their recipe due to our feedback.
Closing
42. We are launching an important research project today, that promises earlier detection of heart diseases. RESET is an inspiring name, and hence I also took a detour to talk about our efforts to improve our eating habits and correct worrying trajectories and reset our dietary habits as well.
43. Preventive care involves many experts and stakeholders. From research inquiries, leveraging advance diagnostics technology, to shaping our mundane daily habits. With more proactive and better government action and support, improved clinical care, efforts of researchers, and exercising of personal responsibility, we can work towards a future where chronic diseases such as heart disease are no longer a leading cause of morbidity and mortality. Thank you.