Exercise is everywhere but …

It may come as a surprise to you, but we have actually made great strides in being more physically active in Singapore.

In 1992, a survey showed that only 8% of Singaporeans exercised regularly (at least 3 times a week)1. Another 16% exercised occasionally (once or twice per week). So, all together, only 24% (or roughly 1 in 4) did some form of exercise every week. 24 years later in 2014, this number has increased 158% to 62%2. 6 in 10 Singaporeans now do some exercise every week—more than half.

Even more impressive was the increase of people that exercise regularly; this number increased by nearly 4 times from the low of 8% in 1992 to 38%. Almost 4 in 10 Singaporeans now exercise at least 3 times a week:

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According to our Ministry of Health (MOH), if we apply the World Health Organization (WHO) guidelines, which include activities such as household chores and walking while commuting, 74% had “sufficient total physical activity” in 20133. That means at least 150 minutes of moderate-intensity activity per week. Yes, 74% of Singaporeans met this requirement.

How do we compare with other countries?

Glad you asked. We are more physically active than Australia, New Zealand, Japan, Germany, France, and many others. In fact, we are ranked 6th worldwide, behind countries such as Vietnam, Thailand, and India:3

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We have worked to become one of the most physically active countries in the world.

We should be proud.

We didn’t get here by chance.

43 years ago, in 1973, we established the Singapore Sports Council (SSC) under the “Sports for All” national policy to improve our physical fitness and encourage mass participation in sports4. Since then, many programs and initiatives have been put in place. Here are some of them:5

  • Master Plan on Sports Facilities (1976-1990): This gave us the first fitness park in the MacRitchie Reservoir (1977), the Singapore Indoor Stadium (1989), the Kallang Squash and Tennis Centre (1978), and the East Coast Lagoon (1976).
  • “Sports for Life” (1996): This program promoted maintaining an active lifestyle throughout the lifetime by participating in sports—especially for senior citizens, housewives, and working adults.
  • “Sporting Singapore” (2001): The goal of this project was to turn Singapore into one of Asia’s top 10 sporting nations by 2010. Singapore Sports Hub was completed in 2014, including our 55,000-capacity National Stadium.
  • Vision 2030 (2012): This will guide sports development for the next 20 years to develop a healthy and resilient population.
  • SSC was renamed Sport Singapore in 2014 with a new slogan, “Live Better through Sports.”

At the same time, our various ministries have also rolled out many healthy lifestyle programs and campaigns to promote physical activities. Some examples include:

  • National Physical Fitness Award (1982)
  • National Healthy Lifestyle Program (1992)
  • Trim and Fit Program (1992)
  • All Companies / Communities Together In Various Exercises (A.C.T.I.V.E.) (1996)
  • Championing Effort Resulting in Improved School Health (CHERISH) (2000)
  • Holistic Health Framework (2007)
  • National Physical Activity Guidelines (2011)
  • Healthy Living Master Plan (2014)

Another, perhaps under appreciated, contributing factor to exercise is our compulsory National Service. Male Singaporeans need to take and pass fitness tests regularly.

Indeed, reminders of exercise are everywhere. There are 65 national associations for just about every conceivable sport, 1,208 fitness corners/parks, 1,235 swimming pools, 45 jogging tracks, 423 soccer fields, 672 outdoor multi-purpose courts, 559 multi-purpose fields, 102 athletic tracks, and 980 multi-purpose indoor halls.6

When Standard Chartered Marathon Singapore was first held in 2002, there were only 6,000 participants. By 2011, the number of participants had swollen to 65,000.7

At this point, it is worthwhile to take a step back and ask: why do we spend so much time and so many resources to be physically active?

Well, because it is good for us. Right?

From the Health Promotion Board (HPB):

  • National Physical Activity Guidelines:8

“Health benefits of regular physical activity include a 20 – 50% reduced risk of premature death, incidence of coronary heart disease, type 2 diabetes, depression, stroke, high blood pressure, colon cancer and breast cancer, to name just a few.”

  • National Physical Activity Guidelines: Summary Guide for Professionals:9

“…There is overwhelming scientific evidence to support the health benefits of physical activity for adults and older adults…”

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The benefits are indeed numerous and impressive.

Okay, after having embarked on this exercise journey more than 40 years ago, what impact has it had on our health? Here are the numbers on prevalence of chronic disease/risk factors from the MOH’s National Health Surveys:10

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The results are not good.

Remember, all four chronic diseases/risk factors above are said to have a strong inverse correlation with physical activity. Physical activity increased significantly, but diabetes, hypertension, and obesity did not drop—they increased. Only high cholesterol number showed improvement.

Especially jarring was the increase in obesity: 118%. More of us are getting fat even though we are exercising more. It appears that exercise has had no positive effects on obesity, diabetes, and hypertension.

These results seem so wrong. How do we explain them?

You might argue that the surveys do not reflect reality. Singaporeans are in fact couch potatoes with a very sedentary lifestyle. Well, the results come from two different surveys conducted by two different ministries, MOH for the National Health Survey and the Ministry of Culture, Community, and Youth (MCCY) for the National Sports Participation Survey. MOH has been regularly conducting these surveys since 1992, using a methodology based on WHO guidelines. MMCY, on the other hand, has been doing these surveys since 1987, using published methodology and help from outside third-party research agencies. Both surveys cover physical activity, and their results and trends do not contradict one another. You would need to show pretty good proof to back up your claim if you thought their surveys were flawed. Also, if your claim is true, wouldn’t that reflect rather sadly on our national character? I mean, despite more than 40 years of healthy lifestyle campaigns and promotion by our government, we still do not want to exercise because we are a recalcitrant people with poor willpower and a low sense of personal responsibility; we don’t listen or do what is clearly in our own best interest.

Or you might argue that it’s not enough for 74% of the population to meet the “minimum physical activity” guidelines. We need 100%. In that case, you need to explain how pushing participation levels from 74% to 100% would do the trick.

Or you might argue that 150 minutes of moderate activity per week is not enough. We need to do more. As an Australian study boldly suggests, we need to increase the recommended activity level five-fold; everybody should aim to do 15 to 20 hours of brisk walking or 6 to 8 hours of running per week.11 Is this realistic for the general population? And what is the science behind this recommendation? In fact, a study has shown that elite high-intensity athletes don’t live any longer than those that meet minimum physical activity guidelines12.

Questioning the value of exercise is difficult. Who is audacious enough to do it openly? It would be like you are trying to sabotage the health and wellbeing of humanity. But we need to understand these results. If the expected results have still not been achieved after more than 40 years of intervention, it’s time to re-examine our understanding. It does not mean cancelling our gym membership or giving up on exercise; it means getting to the bottom of what exercise is really good for and what it is not. Don’t we want to know the real source of the problem?

There are indeed many excellent reasons to exercise. Personally, I am really fond of the exercise that I do: evening walks with my wife, weekly tennis games with my friends, occasional badminton and squash games with my sons, and trips to the gym once a week, again with my wife. I feel good doing these activities, and there is no denying that I feel fitter, stronger, and healthier as a result. Apart from health objectives, sports have also been shown to promote community bonding and to rally and unite the people.

Okay, so why are we not getting the expected results regarding levels of diabetes, obesity, and hypertension?

To lead a healthy lifestyle, we have always been called upon to do two things: eat a healthy diet and exercise regularly. (In our 2014 Healthy Living Master Plan, “Lack of balanced diet and physical activity” is listed as the top challenge to healthy living).13

Between diet and exercise, which is more important? Is it possible that diet plays a much bigger role in chronic diseases than exercise? That means, whatever the benefits of exercise may be, they cannot counteract a bad diet. If you eat a bad diet, it doesn’t matter whether you run 2 hours or 8 hours (or even more) per week; it will not help you lose weight or protect you from diabetes and hypertension. Think of exercise as an umbrella—it will protect you from rain, but it’s powerless against a storm. Bad diet is the storm. Bad diet is primary and exercise is secondary—or maybe even less important.

Or perhaps exercise just makes you feel hungrier, hence you will end up eating more than usual. The more you exercise, the more you will eat—perhaps not immediately, but eventually. Exercise works up an appetite.14

Farfetched, you think? Well, if these theories were true, they would explain the results we see in Singapore.

In a 2011 randomised controlled trial of 107 adults published in the New England Journal of Medicine, researchers wanted to find out what was the best way to lose weight: diet alone, diet and exercise, or exercise only? They found the following interesting results:15

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No, there’s no mistake in Table 5. Those that did only exercise experienced no weight loss. Those that combined diet with exercise lost 9% of their body weight. But the winners were those that dieted without any exercise!

In an editorial titled “It is time to bust the myth of physical inactivity and obesity: you cannot outrun a bad diet” in the British Journal of Sports Medicine in 2015, the authors described the many benefits of exercise in the opening paragraph, before ending saying, “However, physical activity does not promote weight loss.” They then went on to say, “… poor diet now generates more disease than physical inactivity, alcohol and smoking combined.”16

The belief that exercise is good for weight control had its beginning at Harvard back in 1953. The history of how this belief dominated scientific discussions on exercise and weight—and eventually became the consensus that it is today—is a fascinating but unflattering story about poor science.14

“Wait a minute,” you might say, “If you go to the PubMed website run by the US National Library of Medicine and do a search for exercise and weight gain prevention, you will find over 2000 papers published over the past 5 years, with most showing positive results!”17 My answer to you is this: we have something much better—a definitive exercise experiment spanning more than 40 years with many well thought-out intervention strategies involving the whole population of Singapore. We have plenty of data to show our success in raising the physical activity level dramatically and plenty of results to show that this did not stunt the rising trends of obesity, diabetes, and hypertension.   Also, we need to pay heed to Richard Feynman, the late physics Nobel laureate, who famously said:

“It doesn’t matter how beautiful your theory is, it doesn’t matter how smart you are. If it doesn’t agree with experiment, it’s wrong.”

Okay, we seem to be spending a lot of time on obesity. What about diabetes and other chronic diseases? Why are we so obsessed with obesity? Well, because aside from genetics, we think that obesity is the No. 1 risk factor for diabetes.18,19 In fact, the universal advice to reduce your risk of diabetes is to “maintain a healthy weight” by leading a more active lifestyle.18 By reducing obesity, you will reduce diabetes and all of the other diseases that accompany diabetes: heart disease, stroke, kidney failure, blindness, and amputations.20

In 2014, diabetes afflicted 440,000 Singaporeans, costing collectively S$1 billion a year. Large numbers are difficult for our mind to appreciate. Perhaps these statistics can do a better job of conveying how dismal the situation is: about 1 in 2 heart attack patients had diabetes, 2 out of every 3 new kidney failure cases were due to diabetes, and 2 in 5 stroke patients had diabetes. There are over 1,500 amputations per year due to complications arising from diabetes, roughly 4 per day.20

Unless we do something, the grim forecast is that 1 million Singaporeans will be diabetic by 2050. That something is our “war on diabetes.” Our Health Minister said, “The war on diabetes will not be a quick battle, but a long war requiring sustained effort,” and he will chair a new Diabetes Prevention and Care Taskforce to develop and implement a multi-year action plan.21

What is my intention in writing this blog post? Well, I am a stakeholder. Unless I can beat the average Singaporean life expectancy, I will not be around 34 years from now in 2050 to witness whether we have won against the dire prediction of 1 million diabetics. But my wife, my two sons, and their families will. By 2050, I hope they, together with their fellow Singaporeans, will be celebrating and congratulating each other for winning the war; diabetes is now a rare disease, just like it was before the 1970s.22 I hope my two cents here is in line with one of the Diabetes Task Force’s aims to “…engage the whole of society to do their part in this nationwide effort.”20

The importance of physical activity should never be diminished: it will always be a key part of any healthy lifestyle campaign.23 But I hope the data we have seen so far are compelling enough to make us pause a little and to acknowledge the possibility that we have already reached the point of diminishing returns as far as what exercise can do to fight diabetes. Bad diet should warrant much more attention and focus in our action plan. Regarding bad diet, the dialogue should be shifted towards promotion of the “eat less or eliminate” bad food than the “eat more” healthy food approach.24 And we should make it as simple and as unambiguous as possible:

What’s the one food item that we can eliminate from our diet that will have the greatest impact on reversing the diabetes trend? What can we do to discourage its consumption and its availability? We can only choose one food item.

What is a good candidate for this one food item? Here I would like to offer my biased opinion by pointing to two studies. The first study is from Harvard School of Public Health, which includes the following conclusion: 25

“Taken together, current evidence on sugar-sweetened beverage (SSB) and obesity meets all key criteria commonly used to evaluate causal relationships in epidemiology. In other words, there is compelling evidence that SSB intake is causally related to increased risk of obesity. Furthermore, there is also convincing evidence from recent randomized controlled trials that reducing SSB intake decreases risk of weight gain and obesity in children and adolescents.”

The second study is a large econometric analysis of the relationship between sugar consumption and population-level diabetes prevalence for 175 countries.26 The findings: compared to an excess of 150 calories obtained from fat or protein, an excess of 150 calories from sugar will increase the prevalence of diabetes by eleven-fold. 150 calories of sugar is equivalent to about nine teaspoons of sugar or one can of soft drink. HPB estimates that the average daily sugar consumption in Singapore is eleven teaspoons, with the top fifth hitting eighteen teaspoons a day.27

One day, hopefully sooner rather than later, we can see exercise everywhere and in the health statistics.

Thanks for reading, and I welcome your comments and suggestions.

 

Notes:
  1. National Sports Participation Survey 2011 Final Report. Data for 1992 in Figure 2, page 18. Link here.
  2. Sports Index 2014: Key Highlights. Link here.
  3. MOH Report of the Director of Medical Services 2014. Pages 14-15. Link here.
  4. SSC objectives as explained by The Minister for Social Affairs (Encik Othman Bin Wok) – Singapore Sports Council Bill, Sitting No: 21 on 25-07-1973. Link here.
  5. Article on SSC by Lim Tin Seng. Link here.
  6. Sports and Its Role in the Future of Singapore 2012. Link here.
  7. Standard Chartered Marathon Singapore website. Link here.
  8. National Physical Activity Guidelines 2011. Link here.
  9. National Physical Activity Guidelines: Summary Guide for Professionals. Link here.
  10. National Health Survey 2010. MOH website. Link here.
  11. Kyu Hmwe H, Bachman Victoria F, Alexander Lily T, Mumford John Everett, Afshin Ashkan, Estep Kara et al. Physical activity and risk of breast cancer, colon cancer, diabetes, ischemic heart disease, and ischemic stroke events: systematic review and dose-response meta-analysis for the Global Burden of Disease Study 2013 BMJ 2016; 354 :i3857. Link here.
  12. Clarke Philip M, Walter Simon J, Hayen Andrew, Mallon William J, Heijmans Jeroen, Studdert David M et al. Survival of the fittest: retrospective cohort study of the longevity of Olympic medallists in the modern era BMJ 2012; 345 :e8308. Link here.
  13. MOH 2014 Healthy Living Master Plan. Link here.
  14. Taubes Gary. The Scientist and the Stairmaster. 2007 New York Magazine. Link Here.
  15. Villareal DT, Chode S, Parimi N et al. Weight loss, exercise, or both and physical function in obese older adults. N Engl J Med. 2011 Mar 31;364(13):1218-29. Link here.
  16. Malhotra A, Noakes T, Phinney S. It is time to bust the myth of physical inactivity and obesity: you cannot outrun a bad diet. Br J Sports Med doi:10.1136/bjsports-2015-094911. Link here.
  17. James O Hill, John C Peters. Commentary: Physical activity and weight control. Int. J. Epidemiol. (2013) 42 (6): 1840-1842. Link here.
  18. Diabetes – Are You At Risk? HPB website. Link here.
  19. International Diabetes Federation website. Link here.
  20. The War on Diabetes Fact Sheet. MOH. Link here.
  21. MOH to wage war on diabetes. Straits Times. Link here.
  22. When diabetes prevalence was first measured in 1975, the rate was 1.9%. The rate in 2010 was 11.3%, an increase of 495%.
  23. Amy Luke, Richard S Cooper. Physical activity does not influence obesity risk: time to clarify the public health message. Int. J. Epidemiol. (2013) 42 (6): 1831-1836. Link here.
  24. Boyd Swinburn. Commentary: Physical activity as a minor player in the obesity epidemic: what are the deep implications? International Journal of Epidemiology 2013;42:1840–1842. Link here.
  25. Hu, F. B. (2013), Resolved: there is sufficient scientific evidence that decreasing sugar-sweetened beverage consumption will reduce the prevalence of obesity and obesity-related diseases. Obes Rev, 14: 606–619. doi:10.1111/obr.12040. Link here.
  26. Basu S, Yoffe P, Hills N, Lustig RH (2013) The Relationship of Sugar to Population-Level Diabetes Prevalence: An Econometric Analysis of Repeated Cross-Sectional Data. PLoS ONE 8(2): e57873. doi: 10.1371/journal.pone.0057873. Link here.
  27. Fruit juice often laden with sugar, warns HPB. 2014 Straits Times. Link here.