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Impact of Knowledge and Attitude

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247 Preventing Type 2 Diabetes Mellitus—Benson WG Ang et al


Original Article

Impact of Knowledge and Attitudes on Lifestyle Practices in Preventing Type 2


Diabetes Mellitus
Benson WG Ang, 1, Mui Yee Tan, 1, Cheryl MY Goh, 1, Sylwan Rahardja, 1, Beatrice Y Lim, 1, Wenqi Chiew, 1,
Thurston YJ Heng, 1, Kuang Ian Tan, 1, Jenies HX Foo, 1, Sarah ZL Tham, 1, Jason KS Chng, 1, Wei Jie Seow,1,2BSc, MSc, ScD,
Nan Luo,1,2BSc, MSc, PhD

Abstract
Introduction: Diabetes mellitus is a major public health issue in Singapore. To shape
healthcare policies for the primary prevention of diabetes, it is crucial to understand
Singaporeans’ knowledge, attitudes and practices related to diabetes and its prevention.
This study aimed to assess the knowledge, attitudes and lifestyles of individuals without
diabetes. Materials and Methods: A cross-sectional household survey was performed
between 31 January to 3 February 2019 to examine knowledge, attitudes and practices
related to diabetes. Inclusion criteria of the participants included: 1) Singaporeans/
permanent residents, 2) between 30 to 64 years old, and 3) who did not have a diagnosis
of diabetes. Logistic and linear regression models were used to analyse the association of
knowledge and attitudes with physical activity and diet habits, respectively. Results: Among
806 participants, 72.2% did not meet the Health Promotion Board’s physical activity
recommendation. Physical activity was associated with better diabetes knowledge (odds
ratio [OR] 5.38, 95% confidence interval [CI] = 1.65-17.53, P = 0.049), stronger beliefs in
diabetes prevention (OR 3.36, 95% CI = 1.02-11.12, P = 0.047) and lower levels of worry
about diabetes (OR 0.41, 95% CI 0.17-1.00, P = 0.049). Neither knowledge nor beliefs or
worries about diabetes was associated with diet. Conclusion: There is a need to reinforce
the importance of physical activity and healthy diet in preventing diabetes. Although
improving the knowledge level of diabetes may increase physical activity of the population,
it is unlikely to improve dietary choices without effective behaviour change interventions.

Ann Acad Med Singapore 2019;48:247-63


Key words: Healthy diet, Physical activity, Singapore, “War on Diabetes”

Introduction Diabetes also poses a significant burden in Singapore.


Diabetes mellitus is a chronic disease that affects the It accounts for 10% of Singapore’s disease burden10 and
body’s metabolism of sugar. Type 2 diabetes involves cost Singapore over 1 billion dollars in 2010.11In fact, the
insulin resistance and is preventable. Worldwide, type 2 prevalence of diabetes in Singapore is higher than that of
diabetes accounts for the majority of diabetes cases.1 It is the world’s average.10,12 The number of Singaporeans living
a disease of multifactorial pathogenesis2 and modifiable with diabetes might surge from 440,000 in 2014 to 1 million
lifestyle factors include obesity,3 physical inactivity,4 diet5 by 2050,12 with 1 in 3 Singaporeans having a lifetime risk
and alcohol consumption.6 Diabetes leads to debilitating of developing diabetes.13
complications like chronic renal failure,7 acute myocardial In 2016, Singapore’s Ministry of Health (MOH) declared
infarction and stroke.8 It is a worldwide epidemic that a “War on Diabetes” (WoD) to address the magnitude of the
affected 422 million adults (8.5% of the world’s population) problem, implementing preventive interventions targeting
in 20149 and is listed as 1 of 4 priority non-communicable modifiable risk factors. These include primary preventive
diseases by the World Health Organization (WHO).9 measures for diet control (e.g. Healthier Dining Programme,
1
Yong Loo Lin School of Medicine, National University of Singapore, Singapore
2
Saw Swee Hock School of Public Health, National University of Singapore, Singapore
Address for Correspondence: A/Prof Luo Nan, Saw Swee Hock School of Public Health, National University of Singapore, #10-01, Tahir Foundation Build-
ing, 12 Science Drive 2, Singapore 117549.
Email: ephln@nus.edus.sg

Copyright © 2019 Annals, Academy of Medicine, Singapore


Preventing Type 2 Diabetes Mellitus—Benson WG Ang et al 248

Healthier Choice Symbol identifier) and exercise (e.g. participants’ responses with smartphones into a secure
National Steps Challenge), as well as secondary preventive NUS MySurvey portal, in compliance with the Personal
measures to increase screening uptake and early detection Data Protection Act.
(e.g. Diabetes Risk Assessment Tool, Screen for Life Selected questions from the Diabetes Knowledge
subsidies). Since the start of the WoD, the 2018 National Questionnaire (DKQ)18 and Diabetes Knowledge Test
Nutrition Survey showed an overall improvement in (DKT)19,20 were modified to suit the local population to
Singapore’s dietary practices compared to 2010, with assess general knowledge on diabetes and its management.
Singaporeans consuming food with fewer calories and A total score for diabetes knowledge was calculated from
carbohydrates, though there was still high sugar and salt the questionnaire: 16 items from DKQ and 8 items from
intake.14 With regard to exercise, more than a third (36.5%) DKT. Items were scored 1 for a correct response and 0 for
of Singaporeans still have insufficient physical activity.15 incorrect and “I don’t know” responses. Participants’ scores
However, there are no formal studies conducted to assess were represented as a percentage of the total score of 24
the effects of the WoD on the knowledge and attitudes of
(i.e. if a participant answered 16 items correctly, their total
the population.
score is 16/24 X 100 = 66.7%).
Hence, this study aimed to assess the knowledge,
To assess attitudes, the team generated questions about
attitudes and lifestyles of diabetes-free Singaporeans and
worries and beliefs regarding diabetes based on the Tripartite
permanent residents, in an attempt to evaluate the early
Model of Beliefs.21 Questions assessing physical activity
impact of the WoD on healthy lifestyle adoption, with the
were adapted from the Health Promotion Board (HPB)’s
hope of informing the design of future primary preventive
Diabetes Risk Assessment Tool and WHO’s Global
interventions against diabetes. The study objectives were:
Physical Activity Questionnaire.22 Barriers to physical
1) to assess the current physical activity level and dietary
activity were sought using the Health, Knowledge &
habits and identify suboptimal practices despite ongoing
Practices Questionnaire 1999 by The Australian Diabetes,
awareness campaigns, and 2) to determine the association of
knowledge and attitudes of diabetes with lifestyle practices. Obesity and Lifestyle Study.23 To assess diets, questions
were modified from the Dietary Screener Questionnaire24
Materials and Methods in the National Health and Nutrition Examination Survey
Study Design, Case Definition and Data Collection (NHANES), and the Health at Work Questionnaire25 by the
British Heart Foundation. Sociodemographic information
This study used data collected from a cross-sectional, and past medical history were also collected.
questionnaire-based survey administered by trained
interviewers between 31 January and 3 February 2019. To facilitate administration, the questionnaire was
Inclusion criteria were Singapore citizens or permanent translated from English to Chinese. Both language versions
residents without diabetes, aged 30-64 years and who of the questionnaire were tested with interviewers’ families
could comprehend and communicate in English or before data collection. Subsequently, questions were
Mandarin. The age group of 30-64 years old was chosen rephrased to reduce ambiguity and to omit medical jargon.
to represent the young and middle-aged population, with The final questionnaire included a total of 47 questions (see
the age bracket of 30-39 years representing the first big Appendix: Questionnaire).
jump in prevalence.16 Ethical approval was obtained from
the National University of Singapore (NUS) Institutional Statistical Analysis
Review Board. Informed consent was obtained from each Participants’ knowledge, attitudes and diet habits were
individual prior to participation. assessed using percentage scores based on their responses
Six Housing and Development Board (HDB) estates to relevant questions. For diet habits, its association with all
were selected via simple random sampling out of 23 HDB sociodemographic and past medical characteristics was first
towns and 3 HDB estates.17 Thirty blocks per estate and examined using one-way analysis of variance (ANOVA).
50 units per block were randomly selected. Selected units All statistically significant or borderline-significant variables
were approached in order until 10 responses were obtained (0.05 < P ≤0.10) in the univariate analyses were included
per block. in a multivariate linear regression analysis, with knowledge
The survey was conducted over 2 weekdays from 5 and attitudes scores (including beliefs and worries about
pm to 9 pm and 2 weekends from 9 am to 6 pm to avoid diabetes) included as covariates.
underrepresentation of the employed. In households with Exercise was coded as a binary categorical variable
multiple eligible individuals, the most willing individual (meets or does not meet HPB’s recommendations for
was surveyed. physical activity, which is defined as at least 150 minutes of
Interviewers were trained to ensure uniformity in moderate intensity exercise or 60 minutes of high intensity
questionnaire administration. Interviewers manually entered exercise per week). Its association with sociodemographic

August 2019, Vol. 48 No. 8


249 Preventing Type 2 Diabetes Mellitus—Benson WG Ang et al

and medical characteristics was first examined using simple sweets, chocolates or confectionery” (87.1%) at least half
logistic regression. Subsequently, all statistically significant the time. Most participants also chose wholemeal bread
or borderline significant variables were included in a over white bread more than half the time (68.2%). However,
multiple logistic regression model, together with knowledge a majority had suboptimal dietary practices regarding
and attitudes scores to identify factors independently carbohydrates and fats, choosing to base their main meals
associated with meeting recommended physical activity. around starchy foods at least half the time (64.3%). The
Statistical Package for the Social Sciences (SPSS) version distribution of responses to all diet questions are shown
23 was used for data analysis. A value of P <0.05 was in Figure 2.
considered statistically significant for univariate and
multivariate analyses. Factors Associated with Practices
Simple logistic regression analyses showed that Chinese
Results (P = 0.052), females (P <0.001) and participants with
Of the 5400 household units that had been approached, primary or secondary qualifications (P = 0.043) exercised
3526 were contactable, of which 1541 residents were less. Participants living in Yishun exercised more (P =
eligible. Of those eligible, 806 agreed to participate and 0.093, OR 1.55, 95% CI 0.93-2.58) compared to those in
completed all questions without missing responses, yielding Ang Mo Kio. In multivariate analysis, participants who
a response rate of 52.3%. had higher knowledge scores (P = 0.005, OR 5.38, 95%
The mean age (standard deviation [SD]) of the study CI 1.65-17.53), stronger beliefs (P = 0.047, OR 3.36, 95%
sample was 57.2 ± 12.5 years. The majority of participants CI 1.02-11.12), or less worries (P = 0.049, OR 0.41, 95%
were females (60.7%), had qualifications above primary CI 0.17-1.00) exercised more (Table 2).
level (87.1%), monthly household incomes of less than In the analyses of dietary practices, we found that older
S$10,000 (88.0%) and lived in housing units of 4-room or participants (P = 0.002) and participants in Clementi (P
smaller (78.0%); 35.1% of participants had a family history = 0.020) and Yishun (P = 0.002) had healthier dietary
of diabetes and 19.7% had high blood pressure (Table 1). practices. There was no statistically significant association
of knowledge or attitudes with dietary practices (Table 3).
Diabetes Knowledge and Attitudes Race, marital status, household income, type of housing,
The mean knowledge score (SD) of the participants was family history of diabetes and personal history of
59.2 ± 15.1%, with the minimum of 0.0%, maximum of hypertension were not significantly associated with physical
100.0% and median of 58.3%. activity or dietary practices (Tables 2 and 3).
Generally, participants had good knowledge about the
Barriers to More Physical Activity and Healthier Diets
impact of diabetes mellitus on health. For example, 90.8%
of participants answered correctly that “Cuts and abrasions The 3 most commonly cited barriers to increasing physical
on patients with diabetes heal more slowly”. However, only activity were “work” (25.3%), “lack of time” (24.2%) and
14.4% knew that “Eating too much sugar and sweet foods “other priorities” (15.0%). Common barriers to a healthier
is a cause of diabetes” was false. diet included “lack of time” (20.7%), “other priorities”
(18.5%) and “lack of access from workplace” (15.5%).
A total of 49.8% of participants were worried about a future
Participants’ responses are shown in Figure 3.
diagnosis of diabetes. The majority of participants possessed
strong beliefs about diabetes prevention (Fig. 1). For example,
Discussion
86.1% and 87.1% of the participants (strongly) agreed that
their risk of diabetes can be controlled by exercising regularly More Singaporeans had suboptimal exercise levels
and maintaining healthier diets, respectively. compared to a recent study published in “The Lancet Global
Health” (2018) describing worldwide trends in insufficient
Practices physical acitvity,15 which found that 33.3% of populations
in South Asian countries had insufficient physical activity.
A total of 27.8% of participants met the HPB’s
This could be due to differences in their study population
recommendations for physical activity.26 The majority of
which included participants as young as 18 years old who
participants exercised for more than 60 minutes per week
would be more physically active. Singaporeans in our study
(63.4%) and most did light to moderate exercise (85.4%).
are mostly from the working class, where lack of time was
For dietary practices, responses were varied. Most commonly cited as a barrier to more exercise. As overseas
participants chose not to “eat at western fast food outlets or studies and trials have shown that workplace interventions
quick-service restaurants” (92.8%), “consume sweetened significantly increase the level of physical activity27 and
beverages” (87.0%) or “consume sweet cakes, desserts, overall physiological health,28,29,30 quick and

easy activities

Copyright © 2019 Annals, Academy of Medicine, Singapore


Preventing Type 2 Diabetes Mellitus—Benson WG Ang et al 250

Table 1. Sociodemographics of Sample Population


Demographic n % Singapore Population Distribution*
Age (years)
30 ‒ 44 299 37.1 42.7
45 ‒ 64 507 62.9 57.3
Race
Chinese 621 77.0 75.0
Malay 84 10.4 12.1
Indian 80 9.9 9.3
Others 21 2.6 3.6
Gender
Male 317 39.3 48.7
Female 489 60.7 51.3
Marital status
Single 131 16.3 15.5
Married 642 79.7 77.0
Divorced/widowed 33 4.1 4.7
Highest qualification
Primary 104 12.9 21.1
Secondary 236 29.3 18.6
Postsecondary 199 24.7 25.7
University 267 33.1 34.6
Monthly household income
<$2000 214 26.6 19.1
$2000 ‒ $4999 242 30.0 15.8
$5000 ‒ $7999 171 21.2 15.8
$8000 ‒ $10,000 82 10.2 9.6
>$10,000 97 12.0 39.8
Type of housing
2-room flat 61 7.6 4.7
3-room flat 200 24.8 19.1
4-room flat 368 45.7 43.0
5-room, executive, maisonette flats 177 22.0 33.1
Family history of type 2 diabetes
Yes 283 35.1
No 509 63.2
I don’t know 14 1.7
Hypertension
Yes 159 19.7
No 638 79.2
I don’t know 9 1.1
Area of Singapore
Ang Mo Kio (north) 168 20.8 15.7
Bedok (east) 128 15.9 26.6
Bukit Merah (south) 130 16.1 14.3
Bukit Panjang (west) 128 15.9 13.6
Clementi (west) 126 15.6 8.8
Yishun (north) 126 15.6 21.0
*
Department of Statistics, Singapore. Singapore Census Data. Available at: https://www.tablebuilder.singstat.gov.sg/publicfacing/createSpecialTable.
action?refId=15454. Accessed on 22 February 2019.

August 2019, Vol. 48 No. 8


251 Preventing Type 2 Diabetes Mellitus—Benson WG Ang et al

Fig. 1. Participants’ attitudes towards the prevention of diabetes mellitus.

Fig. 2. Responses to questions on dietary practices of participants.

Copyright © 2019 Annals, Academy of Medicine, Singapore


Preventing Type 2 Diabetes Mellitus—Benson WG Ang et al 252

Table 2. Association of Knowledge and Attitudes with Exercise


Demographic % Meets Univariate Odds Ratio Multivariate
Recommendation (n) P Value (95% CI) P Value*
Age (years) 0.148
30 ‒ 44 31.4 (94)
45 ‒ 64 25.6 (130)
Race 0.052 0.059
Chinese 26.9 (167)
Malay 31.0 (26) 1.25 (0.73 ‒ 2.13) 0.423
Indian 31.3 (25) 1.26 (0.74 ‒ 2.15) 0.404
Others 28.6 (6) 3.39 (1.35 ‒ 8.53) 0.009
Gender <0.001 <0.001
Male 36.3 (115)
Female 22.3 (109) 0.48 (0.34 ‒ 0.66) <0.001
Marital status 0.746
Single 33.6 (44)
Married 26.6 (171)
Divorced/widowed 27.3
Highest qualification 0.043 0.477
Primary 22.1 (23)
Secondary 26.3 (62) 1.00 (0.55 ‒ 1.80) 0.991
Postsecondary 26.1 (52) 1.39 (0.76 ‒ 2.55) 0.281
University 32.6 (87) 1.27 (0.68 ‒ 2.22) 0.500
Monthly household income 0.336
<$2000 25.7 (55)
$2000 ‒ $4999 28.1(68)
$5000 ‒ $7999 31.6 (54)
$8000 ‒ $10,000 25.6 (21)
>$10,000 26.8 (26)
Type of housing 0.803
2-room flat 32.8 (20)
3-room flat 26.0 (52)
4-room flat 28.5 (105)
5-room, executive, maisonette flats 26.6 (47)
Area of Singapore 0.057 0.054
Ang Mo Kio (north) 24.4 (41)
Bedok (east) 18.0 (23) 0.65 (0.36 ‒ 1.18) 0.156
Bukit Merah (south) 31.5 (41) 1.49 (0.87 ‒ 2.53) 0.147
Bukit Panjang (west) 30.5 (39) 1.17 (0.68 ‒ 2.01) 0.565
Clementi (west) 30.2 (38) 1.07 (0.62 ‒ 1.84) 0.818
Yishun (north) 33.3 (42) 1.62 (0.94 ‒ 2.79) 0.084
Family history of type 2 diabetes 0.853
Yes 27.6 (78)
No 27.3 (139)
I don’t know 50.0 (7)
CI: Confidence interval
*
Only variables that were statistically significant or borderline-significant in univariate analysis were included in the multivariate analysis.

August 2019, Vol. 48 No. 8


253 Preventing Type 2 Diabetes Mellitus—Benson WG Ang et al

Table 2. Association of Knowledge and Attitudes with Exercise (Cont’d)


Demographic % Meets Univariate Odds Ratio Multivariate
Recommendation (n) P Value (95% CI) P Value*
Hypertension 0.190
Yes 22.6 (36)
No 29.2 (186)
I don’t know 22.2 (2)
Knowledge 5.38 (1.65 ‒ 17.53) 0.005
Worries 0.41 (0.17 ‒ 1.00) 0.049
Beliefs 3.36 (1.02 ‒ 11.12) 0.047
CI: Confidence interval
*
Only variables that were statistically significant or borderline-significant in univariate analysis were included in the multivariate analysis.

Table 3. Association of Knowledge and Attitudes with Diet


Demographic Mean Univariate Regression Multivariate
Score (%) P Value Coefficient P Value*
Age (years) 0.002 0.024 (0.009 ‒ 0.040) 0.002
30 ‒ 44 45.4
45 ‒ 64 47.9 0.024 (0.009 ‒ 0.040) 0.002
Race 0.912
Chinese 46.9
Malay 47.7
Indian 46.6
Others 47.1
Gender 0.503
Male 47.3
Female 46.7
Marital status 0.509
Single 46.0
Married 47.1
Divorced/widowed 48.0
Highest qualification 0.481
Primary 47.2
Secondary 46.9
Postsecondary 47.8
University 46.2
Monthly household income 0.335
<$2000 47.5
$2000 ‒ $4999 46.5
$5000 ‒ $7999 45.8
$8000 ‒ $10,000 47.9
>$10,000 48.1
Type of housing 0.136
2-room flat 44.1
3-room flat 47.5
4-room flat 46.8
5-room, executive, maisonette flats 47.6
*
Only variables that were statistically significant or borderline-significant in univariate analysis were included in the multivariate analysis.

Copyright © 2019 Annals, Academy of Medicine, Singapore


Preventing Type 2 Diabetes Mellitus—Benson WG Ang et al 254

Table 3. Association of Knowledge and Attitudes with Diet (Cont’d)


Demographic Mean Univariate Regression Multivariate
Score (%) P Value Coefficient P Value*
Area of Singapore 0.016 0.008 (0.003 ‒ 0.012) 0.001
Ang Mo Kio (north) 45.4
Bedok (east) 46.3 0.007 (-0.017 ‒ 0.032) 0.562
Bukit Merah (south) 46.0 0.007 (-0.018 ‒ 0.031) 0.580
Bukit Panjang (west) 46.8 0.015 (-0.010 ‒ 0.039) 0.241
Clementi (west) 48.5 0.030 (0.005 ‒ 0.055) 0.020
Yishun (north) 49.3 0.038 (0.014 ‒ 0.063) 0.002
Family history of type 2 diabetes 0.591
Yes 46.5
No 47.1
I don’t know 48.8
Hypertension 0.240
Yes 46.9
No 46.9
I don’t know 53.0
Knowledge 0.021 (-0.030 ‒ 0.072) 0.421
Worries 0.010 (-0.029 ‒ 0.049) 0.610
Beliefs <0.001 (-0.051 ‒ 0.050) 0.997
*
Only variables that were statistically significant or borderline-significant in univariate analysis were included in the multivariate analysis.

could be introduced to encourage more exercise among busy lack of access from home and workplace, cost and other
working adults. Workplace-focused exercise and fitness priorities are possible reasons for unhealthy diet choices.33
programmes with easy accessibility to exercise avenues Furthermore, rice and noodles are staples in Asian cuisine,
such as gyms could be viable options to overcome this making it harder to find alternatives. As such, cheaper and
barrier and positively impact their practices. Additionally, more convenient access to main meals without starchy
a potential reason for females in our study to engage in food items could be introduced to overcome these barriers.
less physical activity (compared to their male counterparts) Singaporeans with better knowledge or stronger beliefs
could be due to the difference in societal gender roles where about diabetes prevention tend to exercise more as they could
women are expected to bear greater responsibilities at home be more health conscious and motivated.34 An Australian
and with childcare,31 and hence less time is dedicated to study reported that one of the main motivators for people
exercise. With regard to older participants making healthier to engage in physical activity is to improve overall health.35
choices, possible reasons for it include: 1) being more health Therefore, efforts should be aimed at improving knowledge,
conscious as they age, 2) having more family members/ which can potentially result in an increase in exercise at
friends diagnosed with diabetes, and 3) having more leisure the population level.
time than younger people. This is further reinforced by HPB’s campaigns promoting
Our study showed that the majority of Singaporeans physical activity such as the “National Steps Challenge”.36
are making healthier diet choices regarding food high in Additionally, due to the beliefs that they are taking active
sugar,14 suggesting that HPB’s “Life’s Sweeter with Less steps in preventing diabetes, these individuals also tended
Sugar” campaign launched in 201432 has been effective. to worry less about developing diabetes as opposed to those
Despite better choices, total sugar intake of Singaporeans who exercised less.
increased to 60 g14 which suggests that Singaporeans are The lack of significant association between knowledge or
consuming more sugars per serving from their food. There attitudes towards diabetes and diet could be due to ingrained
is thus a need to improve Singaporeans’ food choices as cultural food habits. HPB has implemented initiatives such as
they could have a misperception of the amount of sugar “Healthier Hawker Centre” and “Finest Food” programmes
that they are consuming. Most Singaporeans still have to increase provision of healthy food37 and “My Healthier
suboptimal diet practices, choosing to base their main Plate”, “Healthier Choice Symbol” and “Healthy 365” diet
meals around carbohydrates most of the time. Lack of time, journal to promote healthy eating.

August 2019, Vol. 48 No. 8


255 Preventing Type 2 Diabetes Mellitus—Benson WG Ang et al

Fig. 3. Barriers to healthy practices.

However, more could be done to improve the accessibility Residents living in private properties, institutions and
and convenience of healthy eating options and to promote the homeless were not sampled due to limited time and
healthier eating habits. For the latter, some suggestions resources. Data collection was carried out only in English
would be to host reality cooking television programmes or or Chinese due to the lack of Malay- and Tamil-speaking
to create interactive videos on HPB’s websites to reach out interviewers, excluding residents who could not converse
to a wider audience. Building on the success of switching in either language.
to wholegrain food, more specific suggestions on food Residents living within the same unit were not randomly
replacement options such as having fruits for dessert selected for participation. We had disproportionately more
(instead of sweet soup) can be recommended through the females as women were more likely to answer the door and
abovementioned platforms. agree to participate. Our survey questions were adapted
Being a cross-sectional study, causalities between from various validated sources and several new questions
knowledge, attitudes and practices cannot be determined. were crafted to assess the attitudes of Singaporeans.

Copyright © 2019 Annals, Academy of Medicine, Singapore


Preventing Type 2 Diabetes Mellitus—Benson WG Ang et al 256

Conclusion default-document-library/diabetes-info-paper-v6.pdf?sfvrsn=0. Accessed


on 21 February 2019.
This cross-sectional study assessed the association 13. Ministry of Health, Singapore. Singapore Burden of Disease Study,
between diabetes knowledge and attitudes, and the preventive 2010. Singapore: Epidemiology & Disease Control Division, Ministry
practices among middle-aged people without diabetes in of Health; 2014. Available at: http://policy.nl.go.kr/cmmn/FileDown.
do?atchFileId=107157&fileSn=2883. Accessed on 21 February 2019.
Singapore. Our findings suggest that Singapore is headed in
14. Health Promotion Board, Singapore. National Nutrition Survey 2018
the right direction following the declaration of the WoD in Shows Gradual Improvements in Singaporeans’ Dietary Habits. Available
2016. However, individual commitment to healthier lifestyle at: https://www.hpb.gov.sg/article/national-nutrition-survey-2018-shows-
for diabetes prevention needs to be further strengthened. It gradual-improvements-in-singaporeans-dietary-habits. Accessed on 21
February 2019.
is pertinent to encourage both policymakers and researchers
15. Guthold R, Stevens GA, Riley LM, Bull FC. Worldwide trends in
to design and implement more effective interventions that insufficient physical activity from 2001 to 2016: a pooled analysis of
are directed towards healthier dietary practices and higher 358 population-based surveys with 1.9 million participants. The Lancet
physical activity levels among Singaporeans. Glob Health 2018;6:e1077-86.
16. Ministry of Health, Singapore. National Health Survey, 2010. Singapore:
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Acknowledgements
17. Housing & Development Board, Singapore. HDB Map Services. Available
The authors would like to thank: 1) their statistical advisor, A/Prof Alex at: https://services2.hdb.gov.sg/web/fi10/emap.html. Accessed on 22
Cook, for his support and guidance, 2) their Community Health Project February 2019.
colleagues from Yong Loo Lin School of Medicine for their invaluable
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contributions to the study, 3) Singapore Health Promotion Board for its
T, et al. Development, validation and application of computer-linked
support, and 4) all participants who had participated in the study.
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19. Fitzgerald JT, Funnell MM, Hess GE, Barr PA, Anderson RM, Hiss
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Piatt GA. Validation of the Revised Brief Diabetes Knowledge Test
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