Based on Walt and Gilson’s policy analysis triangle framework, we present the findings below.
All respondents in this study stated that the reasons for the development and introduction of the WoD policy were numerous. They include the rising prevalence of diabetes, an ageing population, an extended life expectancy, increasing comorbidities of diabetes and rising healthcare costs. In addition, the respondents attributed the introduction of the policy to an increasing economic burden of diabetes on the working population and the associated potential adverse impact on society. These factors together created the moral impetus for the government to introduce the policy to nudge its people into living a healthy lifestyle, respondents stated.
The causes of diabetes were many. Respondents pointed to a complex interaction of economic, social, cultural, individual, national and environmental factors, leading to the formulation of the policy [25, 26]. For example, they highlighted that access to unhealthy food (exacerbated by food delivery service, technology and ready-to-eat meals), affluence of society, expansion of eating-out places, and roles of the F&B industry (manufacturers and retailers) led to the growing diabetes situation in Singapore. This was seen to be made worse by Singaporeans’ obesogenic lifestyle, characterized by work stress, poor sleep patterns and poor overall eating and living habits. The low health screening uptake and lack of prevention measures at the individual level were other reasons. Genetics, invincibility syndrome, culture, family and personal choice, health literacy, and prevailing treatment models of diabetes were seen to have exacerbated the diabetes situation.
The actors in the WoD comprised policy elites within the government and societal actors, including the F&B business community (SMEs and MNCs), professional associations, healthcare providers, academic think tanks, civil society and the general public. This policy-led implementation, which is inherently cross-sectoral, saw the Diabetes Prevention and Care Taskforce, set up by the Ministry of Health (MOH), facilitating and coordinating the involvement of the various policy actors. Policy actors such as the F&B business community were quick to acknowledge their corporate and social roles to fellow citizens, and promptly moved to align their business and corporate goals with the policy. Respondent 11, who was from a large MNC fast-food chain, stated:
[A]s cliché as it sounds, it is really a social responsibility on the business part to really care for the customers’ well-being.
The role of the civil society was seen in the involvement of professional associations and voluntary welfare organizations to promote healthier eating and living in the community. Funds were directed to academic and healthcare institutions to encourage and foster diabetes-related research to inform policy and practice. Healthcare institutions were seen to expand their ability to offer better diabetes treatment with increased drug subsidies. Schools, workplaces and organizations implemented policies promoting healthier eating on their premises. The general public were engaged through programmes and schemes, although their level of receptivity and engagement towards the policy varied.
In operationalizing the policy, a total of 171 WoD-related organizational documents were analysed. The government, in working with the various policy actors and through public forums and engagements, delivered a slew of measures at different time points following the declaration of the policy. The policy core of WoD, highlighted in the documents, centred primarily on increasing the population’s level of physical activity, improving the quality and quantity of dietary intake, increasing early screening uptake and improving intervention to better control diabetes and its associated complications .
Notably, in the first 2 years of the policy launch, the government actively used words, images and symbols to form winning coalitions with different policy actors, such as the F&B industry and people with diabetes and their caregivers, and through various languages, including dialects and vernacular languages, to address older adults in the public. The modes of the images included posters, health screening booths and media programmes. Some common symbols and schemes, such as the Healthier Choice Symbol (HCS), Healthier Ingredient Development Scheme (HIDS), Healthier Dining Innovation (HDI), Healthier Dining Grant (HDG) and National Steps Challenges™, targeted consumers, F&B enterprises and the general public.
As part of its overall strategy, the government collaborated with the primary care networks (PCNs) to provide more supportive services for people with diabetes . It subsidized basic screening tests for the public to encourage early detection and treatment. It also put in place systems to foster healthier lifestyles, promote good health by employers in the workplace, and facilitate adjustment of lifestyle habits and better decision-making by individuals [28, 29]. Nonstandard drugs in the treatment of diabetes were subsidized, which helped open up options for primary care physicians to offer newer treatments at lower rates to the general public. According to respondent 5, a physician, older generations of drugs were found to have “potential side-effects and less of non-glucose reducing properties”, whereas “newer drugs have heart failure protection, cardiovascular protection”. This could only benefit patients with diabetes.
The health ministry also partnered with the F&B industry to support major beverage companies and companies undertaking innovation to lower sugar content in their products, by fostering a supportive regulatory environment to encourage innovation and experimentation [30, 31]. This is illustrated in the 2017 industry pact, where seven beverage companies pledged to reduce the sugar level in their beverages to 12% or less by 2020 . This incremental decrease signalled the government’s recognition that innovation and (re)formulation of F&B products would need time, and that immediate introduction of any measures or regulation may backfire. Consumers’ taste acceptance of newer and healthier products would also need time to develop. The MOH further supported and enabled the industry to use Singapore as a regional headquarters and launch pad through which to access other Asian markets to sell their healthier products, to provide the economic conditions for the business community to thrive.
Legal parameters were also explored. A public consultation was carried out from 4 December 2018 to 25 January 2019, where a wide range of stakeholders were engaged for their inputs on introducing mandatory front-of-pack nutrient summary labelling, advertising regulations for the least healthy sugar-sweetened beverages (SSBs), excise duty on manufacturers and importers, and banning of higher-sugar prepackaged SSBs . The proposed measures, which were scheduled to be rolled out later in 2020, came nearly three years after the declaration of the WoD, as the government set the stage to create an environment for its people to lead a healthier lifestyle. In November 2019, the MOH went on to introduce the Patient Empowerment for Self-Care Framework, which constituted the first tranche of materials for people with diabetes to more directly effect change in the lives of those with the condition .
Several critical factors enabled or constrained the context in the implementation of the WoD. The following discusses the support for and resistance to the WoD policy, and the potential resources that are further needed for its implementation.
Why war? Why diabetes?
While the WoD served as a useful “policy frame to galvanize government action, and whole-of-society action and attention”, as stated by a government official (P13), there were considerable competing views among non-policy elites. Many non-policy elite actors, for example, questioned the rationale of the WoD. A member of the general public with diabetes (P19) stated: “I am not sure what the logic is behind using diabetes as the condition, because diabetes is so innocent!” Some respondents, such as P12, a diabetes nurse educator, opined that waging a War on Diabetes was unnecessary, and it might risk perpetuating stigma among those with diabetes. She explained that some of her diabetes patients were upset with the policy and were relatively more withdrawn and “shut off” since its introduction due to their perceived stigma. One of her patients told her, “Then I am not going to tell people I have got diabetes,” because people will relate diabetes to medical complications, she said. Others, including P20, a member of the general public, suggested waging a war against sedentary lifestyle or promoting healthier living might be more appropriate.
Policy actors, particularly professional dieticians and the general public, were unclear whether looking solely at individual nutrients, such as sugar, which was seen to be the primary focus of the WoD, was the best approach to stem diabetes. Respondent 18, a representative from the national nutrition and dietetics association, said: “So I think in a sense we cannot look at individual nutrients; we need to look at diet as a whole. This probably has got to be a very consistent message to the public!” Along the same lines, respondents opined that the policy had focused too heavily on packaged SSBs, rather than on freshly cooked or prepared food. Respondent 3, an MNC F&B manufacturer, highlighted: “The beverage may not be the biggest culprit. In fact, the biggest culprit is food.”
Who is the policy for?
Many respondents were unclear of the intended target of the policy. For example, a respondent (P20), a member of the public, reported: “I am not sure who they are targeting, I always thought it is the general public from all age groups.” Another respondent , a medical social worker who works with diabetes patients, said: “It is more for the general public, not for those who already have diabetes.” Respondent 29, who has type 1 diabetes, explained: “Type 1 (diabetics) will switch off because it’s like it is too late for them, they already have diabetes.” This sentiment was echoed by respondents with type 2 diabetes and their caregivers, who highlighted that WoD should more directly address their immediate concerns, which would include helping them with their immediate treatment costs and costs of consumables and related devices. For type 1 diabetes, the causal factors were also unclear and it would not be possible to wage war against type 1 diabetes, stated respondent 29. Some respondents observed, and as a government official acknowledged (P13), that pre-diabetic programmes, whilst carefully designed to reduce diabetes incidence, were more accessible to retirees who were available to attend the programmes during workdays, rather than the “supposed” at-risk and younger diabetic groups, who may hold full-time jobs. Others, such as general public respondents P15 and P17, who were both aver 60 years of age, felt that any programme following the policy is good, as it signals a step forward in the fight against diabetes.
Messaging quality: unclear images, fake news and diet fads
The barrage of messages pertaining to diabetes was found to be at best overwhelming, at worse conflicting and confusing. Messages such as “white rice is bad” and “too much meat will increase diabetes risk” were confusing to the general public respondents. A respondent (P10), an academic, explained: “Everything you [can't eat] eat also cannot. That’s the flip side of pushing things too hard.” The HCS, which had made significant inroads in encouraging healthier F&B consumption, was found to be unclear in its representation. For example, respondent P10 explained: “If we take drinks with the Healthier Choice Symbol (beverages with lower sugar levels), does it mean drinking five bottles of it will be fine?” Rather than emphasizing a particular nutrient such as sugar, some respondents suggested focusing on individual needs, which might be more appropriate. Fake news and popular commercial “diet fads”, such as the ketogenic and Atkins diets, and intermittent fasting were other concerns reported by respondents. Academic and dietician respondents asserted that consistent advice was lacking, and relevant authorities needed to actively clarify unclear images and fake news, and provide consistent messaging on “diet fads” to the public.
With the proliferation of technology, some professionals and general public respondents highlighted the need to regulate healthcare services provided via online apps and virtual coaching programmes. Respondent 18, a dietician, explained that nutrition coaches on these platforms may not have the necessary qualifications and training, and could in fact, do more harm than good to service users or patients. She asserted that necessary regulation of online healthcare services is crucial to mitigate any potential risks of unregulated online healthcare services.
High innovation, production and marketing costs
High innovation, production and marketing costs in the (re)formulation of F&B products were major challenges for the F&B industry respondents. Respondents in this sector explained that taste acceptance for newer and healthier F&B products may not come immediately. F&B retailers, driven by profits, may not be quick to support the sale of healthier products, as the demand for them may not be there at the start. A general manager of an MNC F&B (P3), which produces aerated drinks among other F&B products, highlighted that government support to assist them in engaging in research and development (R&D), marketing, and diversifying and (re)formulating their products would be important and useful. They reported seeing double-digit negative profit margins since the introduction of the policy, and proposed a collaboration that would be beneficial, not just for their corporation, but also for the government and the general public:
We can actually kind of co-create product that we know that is good. Maybe there are certain health concerns, and can do this. Or it could be even at the launch, they [government] could endorse it, or they [government] could give us some promotional funds—how can we jointly, I mean with the help and the support, we can fund it.
Healthier F&B products must also have reach beyond the local market to offset the R&D costs of F&B manufacturers. F&B manufacturer/producer respondents explained that it would mean having to harmonize accreditation of healthier products across countries in order for it to make business sense for them, particularly for a country with a relatively small domestic market like Singapore. To this end, F&B respondents suggested government-to-government and business-to-business collaborations, expressed in forms of shared policies and practices, to give F&B manufacturers the legitimacy to market their (re)formulated healthier products worldwide.
Smaller F&B manufacturers and outlets, such as SMEs, reported acute cash flow issues and were less able to engage in innovation to (re)formulate healthier products. They had to contend with issues such as rising utility costs, rental footprints, high labour costs and limited physical space for stock-keeping units (SKUs) to offer healthier F&B options to their customers. Many respondents questioned the sustainability of rewards, vouchers and subsidies programmes that encourage healthier cooking, eating and living: “Once you finish, then what? I will go back to my own same old way of cooking. I think it’s about sustainability that we need to consider as well before we start on something” (respondent 12, a diabetes nurse educator).
In contrast, F&B retailers, such as larger supermarkets, were least hit by this policy. They were better resourced and better able to offer wider-ranging F&B products with both high and low/no sugar content to their consumers. Larger food establishments, such as restaurants, similarly reported no impact on their profit margins. They were better resourced and were able to offer a wider variety of F&B choices, whether healthier or otherwise, using better-quality and sometimes more expensive ingredients, to meet the needs of consumers who were more willing and able to pay higher prices in these establishments.