Few things in life are as intrinsically linked with the human experience as the food we eat. As Singapore’s Health Minister Ong Ye Kung
said recently, “Food can be medicine if we eat well but it can be poison if we do not.”
He was speaking at the launch of Project RESET, a government-funded initiative to study the population's metabolism, heart, liver health, and lifestyle behaviour to prevent diseases like heart attack and stroke.
The project is just one response to the fact that
worldwide, one in three people have hypertension. In Singapore, nine in 10 people exceed their recommended sodium intake by 80 per cent, consuming 3,600 mg of sodium per day, as compared to the World Health Organisation (WHO) recommendation of 2,000 mg. This is largely attributed to
salt and sauces added during food preparation and from meals eaten outside the home.
In fact, the salt content of foods prepared by professional cooks has gone up. For example, steamed chicken rice — a staple of Singapore hawker centres — now has
1,565 mg of sodium compared with 949 mg around a decade ago.
Excessive intake of sodium can result in, among other things, hypertension, or high blood pressure, which can lead to serious health conditions like strokes, cardiovascular disease, and kidney failure.
Such conditions can place a heavy burden on healthcare systems. A 2018
study found that cardiovascular diseases result in US$8.1 billion in direct and indirect costs on individuals, households, and public finances in Singapore.
Singapore’s policy mix
The Ministry of Health (MOH), through the Health Promotion Board (HPB), spearheads national health initiatives to promote health. Said Dr Phua Kai Hong, Adjunct Senior Research Fellow at the Institute of Policy Studies, Lee Kuan Yew School of Public Policy: “The strategies and plans taken must be broad and integrated enough for any impact on the health system or on society as a whole, and thus cannot be carried out on its own just by an agency or its programmes.”
The HPB, which has set a target of
reducing sodium intake by 15 per cent by 2026, has encouraged the reformulation of reduced-sodium alternatives for home use.
Since 2018, the HPB has been providing grant support to sauce manufacturers, specifically those who supply the food service sector. This support is offered through the Healthier Ingredient Development Scheme, which aims to help them reformulate their products to meet reduced-sodium guidelines. In May 2021, lower-sodium guidelines were introduced into the Whole-of-Government Healthier Catering policy. These guidelines require all caterers engaged by government procuring entities to use lower-sodium ingredients for cooking and food preparation.
The hurdles
One challenge to using low-sodium sauces and salt is that they can affect the shelf life of food. Salt plays a crucial role in controlling bacteria growth, so
reducing sodium content may result in shorter food preservation, which may affect the F&B industry’s bottom line.
Also, the higher cost of low-sodium salt, such as K-salt, can be up to 10 times more expensive than regular table salt, and might be a deterrence to those who are price-conscious.
Additionally, Dr Phua noted that Singaporeans’ rising affluence has shifted eating patterns, which may not necessarily provide the healthiest options. He said: “Singaporeans are not only eating more outside but increasingly, their meals consumed at home will be prepared by foreign domestics.”
He added: “We cannot directly reduce the intake of salt (or carbohydrates or sugary drinks or anything harmful, when we blindly consume the most convenient food sources available. Are other healthier alternatives as accessible and affordable? With the rising costs of fresh foods in Singapore, will the need to procure and preserve these lead to higher prices? “
Therefore, the ones doing the cooking and the buying of food, he said, will be most critical in determining the food composition and, eventually, the person’s food intake.
Prospects for success
Singapore has a good track record of shifting the population’s behaviour, said Dr Phua, citing how past programmes such as the one for family planning, has achieved success, albeit through some trial and error in the incentives and disincentives.
How then can the behaviour towards food choices be changed? “In public health, prevention is efficiently and effectively carried out with the three E’s of education, enforcement and empowerment,” said Dr Phua.
In income-conscious Singapore, the economic imperative plays a paramount role.
Therefore, Dr Phua suggests adding a “fourth ‘E’ – economic incentives/disincentives, as successfully deployed in past behavioural change policies”.
Next steps
The government, through the HPB, has committed to engaging the industry to support the availability of healthier options, and will also intensify public education to raise awareness of healthier choices.
Several countries worldwide, such as Hungary, Mexico, Fiji, and Tonga, have implemented
sodium taxes on processed foods with high sodium content. While Singapore does not have such a tax, the government said it will study the issue of excessive sodium intake, and the MOH will continue to adopt other fiscal and regulatory approaches.
At the individual level, Dr Phua recommends stakeholder analysis that involves a “more detailed analysis of the people doing the grocery shopping, food preparation, and cooking, and their interests to promote healthy eating in Singapore”.
He added: “What are their motivation and challenges on a day-to-day basis? To the actual consumers in the different groups, what are facilitators and barriers to eating healthily?”
He said that the economics of influencing behaviour should also be studied to shape policies and programmes that are more relevant to a price-sensitive economy in Singapore.
“How (do we) increase consumer choice not only by raising awareness of food labelling but creating various means of incentivising people to want to consume healthy foods through making better economic decisions?”
Citing an example, he said: “The right price will be set in any purchase when the government gives subsidies in the form of grants, or taxes by levying extra charges for reduction in the consumption of salt intake.”
Tapping on business management strategies such as social marketing can also be a useful tool to influence behaviour. Social marketing programmes are based on six benchmark criteria: focusing on behaviour change, market research, market segmentation, exchange, competition, and establishing the right marketing mix known as the four P’s (product, price, place, promotion).
“It is an approach to change health behaviours. It can provide a useful framework for systematically understanding barriers to and benefits of the targeted health products.”
As with all new initiatives, Dr Phua said that the likelihood for success often remains in how these programmes must first be trialled and evaluated for factors such as efficiency, cost-effectiveness, quality, impact, and unintended consequences.