Every day around 4pm, Dr Adrian Wang, a psychiatrist, reaches for a Kit Kat in the office fridge. He knows it means excess calories but he finds it hard to resist snacking.

The power of habit is hard to counter, especially when the mind is able to persuade so well. Dr Wang says resignedly: “We tell ourselves: It’s been a long day; we’re stressed. We deserve that Kit Kat.”

According to research, what we do is often dictated by habit. This means we rarely act as a result of conscious decisions, but rely mostly on set routines.

Reaching for that Kit Kat, sipping on Coke or taking the escalator instead of the stairs are all force of habit we seldom question.

New York Times writer Charles Duhigg’s book The Power of Habit explains why we do things in certain ways and how we can change that.

Every habit follows a psychological pattern Mr Duhigg calls a “habit loop” that consists of first, a cue that makes the brain go into “auto” mode.

This unleashes the second part of the loop which is the behaviour or the routine.

The third part is the reward you receive that makes your brain “like” it and remember the loop in future.

What is heartening is that it’s never too late to break a habit. The best way to do that, writes Mr Duhigg, is to understand the “habit loop”. Once you understand it, you will be able to identify the cue and can break the habit, or replace it with a more beneficial one.

Investigating Singaporeans’ health habits

Understanding habits and how to change them could be the key to getting more Singaporeans to lead healthier lifestyles.

According to a recent National Health Survey, 40% of Singapore residents don’t exercise enough. The obesity prevalence increased from 6.9% (2004) to 10.8% (2010), while the prevalence of diabetes among adults aged 18 to 69 rose from 8.2% (2004) to 11.3% (2010). Currently one in every nine Singaporeans has Type 2 diabetes, which is often linked to obesity and a sedentary lifestyle.

To facilitate its work in promoting a healthy lifestyle for the nation, the Health Promotion Board (HPB) conducts studies to assess and understand the determinants of major health issues and pertinent behaviours.

Such studies are supplemented by consumer research which provides insight on why people behave the way they do, and the triggers for behavioural change. Together, these studies guide the shaping of policies and programmes, and enable HPB to monitor their effectiveness.

For instance, HPB found that three out of four seniors were not going for health screening or following up with doctors after they were screened, because they viewed these as inconvenient, inaccessible and sometimes unaffordable.

HPB thus introduced “all-in-one” screening sessions in the community that put together all the recommended tests for the elderly, thereby saving travelling time and money for seniors. In the four-hour sessions, seniors are checked for chronic diseases, certain cancers and age-related decline in functions. They are also given on-site follow-up consultations by a team of GPs, dentists, optometrists, pharmacists and counsellors.

Volunteers are also on hand to help seniors sign up for the Community Health Assist Scheme that allows them to tap subsidies for medical treatment at their neighbourhood doctors.

Creating exercise habits

Through their surveys, HPB also found out that many Singaporeans lack the time to exercise due to work or family commitments, while others just find going to the gym too difficult to fit into their weekly routine.

To get Singaporeans moving, HPB had to trigger the formation of new exercise habits based on the “habit loop”, while bearing in mind the mental barriers.

So in late 2011, it went out in a big way to “repackage” exercise from something that was time-consuming and gym-based, to something that can be done anywhere, anytime in 10-minute blocks.

This was motivated by recent research that shows that 150 minutes of moderately intense workouts (in 10-minute blocks) a week can be beneficial for health.

To engage the population, HPB asked them to come up with ways to clock up 150 minutes of physical activity a week. A video contest got people to share innovative ways of integrating exercise into daily life. One winner shared how a skipping rope break could relieve the monotony of school or work, and inject fun too.

Also, eye-catching, colourful stickers (the cue) at MRT stations exhorted commuters to take a light walk (the behaviour) up the stairs to burn double the calories (the reward), converting the stations into “giant exercise machines” and an exercise opportunity that could be built into daily routine. HDB staircases were also highlighted as a convenient place for people to burn calories.

If a person sees the cue to take the stairs often enough, and is rewarded (knowing he has burned more calories or is feeling more sprightly over time), there is a good chance of him adopting this new habit loop.

Meanwhile the social element of physical activity was introduced to make it fun and engaging. Shopping malls were roped in to promote walks and community aerobics since Singaporeans are known to love window shopping and hanging out at malls.

Starting young

Aware of the power of habit, HPB is also working with parents and schools to influence children’s health and eating habits from an early age. For instance, it has partnered primary schools and childcare centres to offer children healthier bento-style set meals.

Parents are also encouraged to model healthy habits such as eating plenty of fruits and vegetables, practising good hygiene, and even maintaining a positive attitude in life.

Admittedly, it isn’t easy to break a habit – as can be seen from the number of smokers who struggle to quit. It is cruel, almost, to hold back someone from that bowl of laksa when everyone else is tucking in.

So instead of expecting Singaporeans to go at it alone, HPB wants to create a supportive social movement that will make healthy living a social norm. Its Chief Executive, Mr Ang Hak Seng, says this will be the agency’s priority for the coming decade.

It intends to make a healthy lifestyle the “default” lifestyle for Singaporeans by transforming existing infrastructure – parks, shopping malls, hawker centres, coffee shops and Community Clubs – into health-promoting environments.

By making use of the various spaces or facilities that impact people’s lives, HPB aims to change the way Singaporeans work, live and play.

Dishing out healthier options

A good example of co-creating solutions on the ground and influencing the environment is HPB’s Healthier Hawker Programme.

The programme began in 2011 at the Yuhua Hawker Centre at Block 347 in Jurong East Avenue 1. HPB surveys have shown that hawker centres play a huge role in national dietary habits, as 60% of Singaporeans eat out at least four times a week at hawker centres.

“The hawker centre is an ideal location to introduce healthier food options since it is not only a popular place where people eat, but also a ‘community space’ where they meet,” says Mr Ang.

One way of offering a healthier choice is to get Singaporeans to eat more food made with whole grains. Eating whole grain foods reduces the risk of chronic diseases such as stroke, heart disease and cancer.

Knowing that the average Singaporean slurps down at least one serving of noodles daily, HPB worked with hawkers at Yuhua to create healthier noodle dishes using whole grain noodles, while keeping prices affordable.

A local SME was roped in to create a whole grain noodle and HPB sent in its chefs to train the hawkers in cooking the noodle.

This approach was repeated at food centres at Haig Road, Eunos Crescent and Geylang Serai in 2012.

There, the unhealthy ingredients targeted were coconut milk and palm oil – sources of saturated fat – used in the rich lemak and deep-fried dishes beloved by the Malay community.

HPB worked with a local SME to create a blend of vegetable oil with 20% less saturated fat than palm oil, and sold at a comparable price.

HPB also helped the hawkers to aggregate orders for brown rice, whole grain noodles and healthier oil blends, enabling them to keep costs low. The Healthier Hawker Programme is expected to be introduced to 17 more hawker centres and coffee shops by end-2012.

Says Mr Ang: “We have ‘The Healthier Choice Symbol’ and calorie counts stated on the signboards. They serve as visual cues for customers. When they queue up for the healthier foods, it is in turn a signal to the hawkers about customer preferences for healthier choices. In time, the success of the early adopters of the Healthier Hawker Programme will influence other hawkers to sign up. This can make healthy eating pervasive.”

Fanning out to help others

Ultimately, HPB envisions roping in the whole community to make healthy living pervasive.

To do so, it has an ambitious plan of introducing 10,000 Health Ambassadors – they could be ex-smokers, grassroots leaders, or retirees – by 2015 so that “every Singapore household can be impacted by at least one volunteer,” says Mr Ang.

There are now 2,500 trained volunteers at HPB’s Health Promotion Academy, which was set up through a collaboration with the Saw Swee Hock School of Public Health at the National University of Singapore.

“Our Health Ambassadors are our change agents who have social ties with the community and can help to achieve that inside-out change to catalyse healthy living,” Mr Ang says. “After all, the most effective way of getting a person to quit smoking is to have an ex-smoker talk to him and walk him through the journey as he is vulnerable to relapse.”

What is encouraging is that apart from HPB ’s efforts, there are other similar outreach efforts by the public.

Public efforts

Dr Tan Chong Keat, 25, now a medical officer at Tan Tock Seng Hospital, initiated the voluntary, student-led Neighbourhood Health Screening Programme during his second year at medical school.

The group of medical students went door-to-door to one-room rental flat dwellers in Taman Jurong and MacPherson to carry out health screenings aimed at early detection and intervention of chronic diseases.

Now into its fifth year, the programme sees new batches of medical students continue to return year after year to monitor those who need screening. When first visited, some residents had not seen a doctor in 10 years.

What the medical students realized through their rounds was that the poor simply needed a person to reach out to them and to explain why undetected diseases can be a costly time bomb. Diabetes, for instance, if not managed, can lead progressively to gangrene, stroke and chronic heart and renal disease.

“By seeing the residents in their actual living conditions, I got to understand why great health schemes can be futile if enjoyed by none because of a lack of awareness. It is important that we reach out and go door-to-door to understand the residents,” says Dr Tan.

He is heartened to see that the effort has helped many residents change their attitude toward check-ups, and they are now taking better care of themselves. One single mother was moved by the students to deal with her depression, so that she could take better care of her children.

Different folks, different strokes

Even if the statistics show that obesity is growing annually, they also show that the percentage of people who do exercise regularly has inched upwards – from 17% (2004) to 19% (2010). So yes, there are new converts to a healthier lifestyle every year. But for those who require more prodding and support, the role of the entire community will be vital.

As such, HPB intends to aggressively set the pace for healthier living – with the help of Singaporeans.

“There is a strong desire for Singaporeans now to take ownership. Some think Singaporeans becoming vocal is a nightmare but I see it as an opportunity,” says Mr Ang. “People are savvy about the lifestyle changes they have to make and we need to help them – it’s up to you and me to help them make the change and create the environment to sustain it.”

Making a nation healthy is a marathon – it is time to break out the running shoes and get started now.