J Frailty Aging 2023;in press Original Research

Published online July 13, 2023, http://dx.doi.org/10.14283/jfa.2023.31

Strengthening Muscle Health of Community-Dwelling Older Adults in

Singapore: Evidence Towards Clinical Implementation
A.B. Maier1,2,3, S.T.H. Chew4, J. Goh2,3,5, F.H.X. Koh6, N.C. Tan7
1. Faculty of Behavioural and Movement Sciences, Department of Human Movement Sciences, @AgeAmsterdam, Vrije Universiteit, Amsterdam Movement Sciences, Amsterdam, The
Netherlands; 2. Healthy Longevity Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; 3. Centre for Healthy Longevity,
@AgeSingapore, National University Health System, Singapore; 4. Department of Geriatric Medicine, Changi General Hospital, Singapore Health Services (Simei Campus), Singapore;
5. Department of Physiology, National University of Singapore (NUS), Singapore; 6. Sengkang General Hospital, Singapore; 7. SingHealth Polyclinics, Singapore.

Corresponding Author: Professor Andrea B. Maier, Centre for Healthy Longevity, National University of Singapore, 29 Medical Drive, Singapore; Email address: [email protected]

Abstract strength and/or physical performance in older individuals

The prevalence of sarcopenia will inevitably increase as the population is defined as sarcopenia (3). Globally, sarcopenia affects
ages in Singapore, rendering it a growing public health concern approximately 10% of community-dwelling older adults (4,
with a significant impact on healthcare resources. This article firstly 5). Sarcopenia often coexists as comorbid disease (6) and with
summarizes the current understanding of the epidemiology, diagnosis malnutrition (7, 8), and is now regarded as a precursor to frailty
and management of sarcopenia, focusing on community-dwelling older (9). It is a major determinant of falls and fractures (10), reduced
individuals. Early identification is key to preventing and minimizing
ability to perform activities of daily living (ADLs) (11), poor
muscle loss. Appropriate interventions, including resistance exercise
training, nutritional interventions and prehabilitation program, should
health-related quality of life (HRQoL), poor post-operative
be tailored to each patient. We suggest several key actions to ultimately outcomes (12, 13) and mortality (14–19).
improve awareness and overcome challenges in identifying and The world population is aging rapidly – 1 in 6 people will
managing sarcopenia to improve patient outcomes. A paradigm shift be aged 60 years old or above by 2030 (20). In Singapore,
where muscle health is seen as an integral component to maintaining about 1 in 4 people (23.8%) will be aged 65 and above by
good health with longer lifespan is needed. Education – of healthcare 2030 (21). Given the aging population worldwide and the
professionals and the public – serves as the foundation to improving inevitable increase in the prevalence of sarcopenia in the older
awareness of muscle health and sarcopenia, and to promoting physical population, skeletal muscle health will become a growing
exercise across the age spectrum for sarcopenia prevention. The use
societal concern and a major source of healthcare utilization.
of cost-effective evidence-based modalities (e.g., calf circumference
measurement, 5-times chair stand test or bioelectric impedance
Timely diagnosis, early intervention, and management of
assessment) enable early identification of muscle loss in routine practice. sarcopenia and associated risk factors are critical to improve
Providing subsidies for nutritional interventions (e.g., oral nutritional patient outcomes. However, knowledge regarding sarcopenia
supplements) and exercise (e.g., ActiveSG gym membership) would is poor amongst older adults and healthcare providers (HCPs),
encourage uptake of and adherence to interventions. Further high- thus accurately diagnosing and managing the condition has
quality research on interventions and their outcomes is important to been underwhelming (22–24).
determine the optimal strategy in different patient populations and to Early detection of sarcopenia in at-risk older adults with
demonstrate clinical significance and value of addressing sarcopenia. evidence-based targeted interventions is required to prevent
Having local champions within healthcare institution would facilitate
and reverse progression throughout the continuum of care.
the much-needed change in healthcare culture where muscle health is a
part of routine clinical practice.
In this context, the purpose of this review is to address these
needs by summarizing the current understanding of the
Key words: Sarcopenia, muscles, aged, diagnosis, Singapore. epidemiology, diagnosis, and management of sarcopenia, with
a focus on community-dwelling older individuals. We also
aim to provide a concerted approach to generate awareness,
overcome diagnostic and interventional challenges, and to
Introduction promote a holistic approach towards muscle health sustenance

A
in Singapore.
ging is associated with progressive deterioration in
physiological systems (1). For the musculoskeletal Epidemiology of sarcopenia
system, age-related changes include skeletal muscle
cell atrophy and joint degeneration, which together cause The prevalence of sarcopenia varies substantially, which
declines in lean body mass and diminished functional ability. may be attributed, at least in part, to the measurement scale
Muscle health is defined by the presence of adequate muscle used for assessment. In a meta-analysis of Asian and European
mass and muscle function, and muscle function in itself is adults 60 years and older, the prevalence of sarcopenia was
defined as having adequate muscle strength and physical 11% and 9% among community-dwelling men and women,
performance (2). The presence of low skeletal muscle mass, respectively (5). The meta-analysis also reported a higher
Received March 8, 2023
Accepted for publication June 19, 2023
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 STRENGTHENING MUSCLE HEALTH OF COMMUNITY-DWELLING OLDER ADULTS IN SINGAPORE

Table 1. 2019 Asian Working Group for Sarcopenia consensus for diagnosis of sarcopenia in community-dwelling adults (3)
Measurement Criteria
Case finding
Calf circumference OR Men: <34 cm
Women: <33 cm
SARC-F OR ≥4
SARC-CalF ≥11
Assessment
Muscle strength Handgrip strength Men: <28 kg
Women: <18 kg
Physical performance 5-time chair stand test ≥12 seconds
Confirmatory diagnosis
Muscle strength Handgrip strength Men: <28 kg
Women: <18 kg
Physical performance 6-meter walk OR <1.0 m/s
5-time chair stand test OR ≥12 seconds
Short Physical Performance Battery ≤9
Appendicular skeletal muscle mass Dual-energy X-ray absorptiometry OR Men: <7.0 kg/m2; Women: <5.4 kg/m2
Bioelectrical impedance analysis Mean: <7.0 kg/m2; Women: <5.7 kg/m2
Severity classification
Sarcopenia Low ASM + low muscle strength OR
Low physical performance
Severe sarcopenia Low ASM + low muscle strength AND
Low physical performance
ASM, appendicular skeletal muscle mass.

prevalence of sarcopenia among hospitalized individuals (23% (18, 42–44). Furthermore, low muscle mass is associated
in men and 24% in women) and individuals living in nursing with higher adverse post-surgical outcomes and mortality
homes (51% in men and 31% in women) (5). In community- among geriatric patients (13). Sarcopenia is also associated
dwelling older adults (≥50 years) in Singapore, the reported with decreased disease-free survival and overall survival of
prevalence of sarcopenia is 23%–46% (25–30). The prevalence oncology patients (18, 44, 45). These highlight the importance
may be as high as 76% in community-dwelling older adults of identifying and counteracting sarcopenia in the older pre-
(≥65 years) at risk of malnutrition, assessed using the Asian operative population as well as oncology patients.
Working Group for Sarcopenia 2019 criteria (31).
The degree of sarcopenia depends on the presence of risk Sarcopenia definition and diagnosis
factors, including age, habitual levels of physical activity,
malnutrition/malnutrition risk, and presence of comorbid First introduced in 1988, sarcopenia was originally defined
diseases, such as cardiovascular disease, cognitive impairment as loss of appendicular muscle mass in older individuals
and type 2 diabetes mellitus (T2DM) (32). Sarcopenia is measured by dual energy x-ray absorptiometry (46). This
highly prevalent in individuals with T2DM (31.1%) (6) and definition was revised in 2010 to include both low muscle
is associated with reduced energy and omega-3 fatty acid mass, muscle strength and/or physical performance, which was
intake (33, 34) and lower participation rates in regular physical adopted by several consensus groups (3, 47). Subsequently,
activity (35, 36). Low body mass index is also associated with various cut-offs to define sarcopenia of aging have been
sarcopenia in older patients with T2DM (37, 38). However, in employed, emphasizing the need for standardization and
a meta-analysis of individuals with T2DM of all age groups, consideration of appropriate cut-offs for different ethnic
those with T2DM showed lower muscle performance and groups. Notably, screening tools for sarcopenia, such as the
strength, but comparable muscle mass, compared with those SARC-F, are limited because of its low-to-moderate sensitivity
who are normoglycemic (39). (48), therefore necessitating the use of diagnostic criteria for
The association between sarcopenia, malnutrition, and sarcopenia without screening for identification in high-risk
frailty with poor post-operative outcomes is also increasingly groups (3, 49).
recognized (12, 40, 41), with the prevalence of sarcopenia The Asian Working Group for Sarcopenia 2019 (AWGS
ranging between 25–42% among pre-operative individuals 2019) issued a consensus update on sarcopenia screening and
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diagnosis (3), which is utilized in Singapore. The previous strength and balance training on functional status and balance
sarcopenia definition was maintained, but the diagnostic confidence (64). Telerehabilitation is a useful alternative for
algorithm, protocols and some criteria were revised (Table 1). improving physical fitness and muscle strength in older adults,
The AWGS 2019 consensus divides diagnosis into community particularly for those who face challenges in daily commuting
and hospital settings, advocating for a case-finding approach (65).
based on risk factors, looking for symptoms when relevant
symptoms are reported (e.g., falling, weakness, slowness, self- Nutritional intervention
reported muscle wasting, difficulties carrying out ADLs). In the
consensus, the presence of low muscle strength or poor physical The onset and progression of sarcopenia is multifactorial
performance is sufficient for diagnosis of probable sarcopenia and includes reduced nutrient intake and absorption (66). The
and implementation of interventions. Diagnosis of sarcopenia impact of malnutrition on muscle mass is recognised (8), and
requires the additional assessment and confirmation of low low muscle mass is now one of the criteria for the diagnosis
muscle mass, while the presence of all three of low muscle of malnutrition based on the Global Leadership Initiative on
strength, low physical performance, and low muscle mass Malnutrition consensus criteria (67). The recently published
indicate severe sarcopenia. Diagnostic measures of sarcopenia AWGS Expert Consensus on the role of nutrition in muscle
have to be performed by trained HCPs, with the physician being health recommends that targeted nutritional requirements
the gateway to the diagnosis of sarcopenia. should primarily be met via regular dietary patterns prior
to dietary enrichment or supplementation (68). The ESPEN
Sarcopenia interventions clinical practice guidelines recommend an energy intake of 30
kcal/kg body weight/day and a daily protein intake of at least 1
Physical exercise g/kg body weight for older individuals; this should be adjusted
according to individual nutritional status, levels of habitual
Regular physical exercise can modulate the biological physical activity, disease state and tolerance (69). Nutritional
hallmarks of aging to delay age-related chronic diseases and counselling and education should also be offered by HCPs to
maintain functional capacity (50). The mechanisms responsible help older individuals achieve their nutritional intake goals (68,
for the effects of lifelong exercise that positively affect muscle 69). Communal or social eating can also promote regular food
health may act through the promotion of anti-inflammatory intake among older individuals (68).
pathways in skeletal muscle, largely through the release of The benefits of nutritional supplementation to manage
muscle-derived myokines (51–53). Exercise, including sarcopenia in older adults have been well described.
endurance training and resistance training, has been shown to A systematic review concluded that several nutritional
improve muscle oxidative capacity in older adults (54, 55), interventions, including amino acids, creatine, beta-hydroxy-
which in turn improves muscle function. beta-methylbutyrate (HMB) and dietary protein with amino
From a public health perspective, a higher number of acids supplementation, contributed to improved muscle mass in
steps taken by an older individual has been demonstrated to older adults (70). In Singapore, the use of HMB in community-
be strongly and consistently associated with better clinical dwelling older adults at risk of malnutrition improved
outcomes, including greater muscular strength (56). There nutritional outcomes and reversed risk of malnutrition,
is also consensus for resistance exercise training (RET) as a leading to significant improvement in leg strength (12.85 ±
key approach to manage sarcopenia (57, 58). A meta-analysis 0.22 kg vs 12.17 ± 0.22 kg at day 90) and handgrip strength
found that the intensity of RET is positively associated with (14.18 ± 0.17 kg vs 13.70 ± 0.17 kg for females at day 180)
the degree of muscle strength improvement in older adults (57). compared to control group (71). Significantly greater calf
Progressive RET is recommended to improve muscle strength circumference (30.64 ± 0.17 cm vs 30.24 ± 0.16 cm at day 90)
in older adults; this involves the use of free-weight or machines, was also seen following HMB use among participants with
where multiple- and single-joint exercises are administered, low appendicular skeletal mass index (ASMI) at baseline (71).
with slow-to-moderate lifting velocity for 1–3 sets/exercise, at Vitamin D supplementation has been shown to have a beneficial
60–80% of 1 repetition maximum, for 8–12 repetitions with 1–3 effect on muscle strength (72). Furthermore, the AWGS Expert
minutes of rest in between sets, and a frequency of 2–3 days/ Consensus group recommends that vitamin D status should be
week (59, 60). Both the American College of Sports Medicine assessed in patients at risk of malnutrition or sarcopenia (68).
and World Health Organization (WHO) also recommends A vitamin D and leucine-enriched whey protein oral nutrition
muscle-strengthening exercises at moderate or greater intensity supplement (ONS) used for 13 weeks improved muscle mass
involving all major muscle groups on 2 or more days a week and lower-extremity function in older adults with sarcopenia
for older adults (61, 62). In addition to the multiple metabolic (66). A systematic review and meta-analysis showed that while
and physiological aerobic benefits from RET, the improvement leucine supplementation alone has no effect on muscle mass
in muscle power in itself is important as it is a predictor of and strength, leucine-combined supplementation including with
functional capacity, and hence may help prevent loss or decline vitamin D demonstrated significant benefit for muscle strength
in functional ability (59). and performance in older adults (73). As such, ONS and other
Physical exercise has also been shown to benefit muscle specialized nutrients (e.g., HMB) can be added if nutritional
health in individuals with T2DM, including positive effects of requirements are still not met, or if deficiencies are identified in
resistance training on lower body strength (63), and structured older adults (68).
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 STRENGTHENING MUSCLE HEALTH OF COMMUNITY-DWELLING OLDER ADULTS IN SINGAPORE

Combined physical exercise and nutritional while nutritional optimization aims to correct pre-operative
intervention malnutrition and support exercise training (80). Psychological
support during prehabilitation is important to improve anxiety
and depression, and to help patients develop self-efficacy for
Combined interventions that include exercise and nutritional
prehabilitation and surgery (80). Data suggests the benefit of
intervention significantly improve muscle health. Combined
prehabilitation in older patients undergoing surgery (81, 82).
progressive RET and dietary protein intervention for 12
Prehabilitation is associated with positive surgical, oncological,
weeks was effective in improving lean body mass and muscle
functional and patient-reported outcomes and improved
strength in community-dwelling older adults (74). Both protein
healthcare cost savings (83, 84). In Singapore, a surgical
supplementation and RET resulted in greater muscle mass
prehabilitation program for older adults has been successfully
(i.e., appendicular muscle mass and fat-free mass) and muscle
implemented in Sengkang General Hospital. The program
strength (i.e., handgrip strength, knee extension strength and
includes dietitian assessment and nutritional supplementation;
leg press strength) in older adults (75, 76). Combined vitamin D
physiotherapy assessment, RET and deep breathing exercise;
supplementation and RET also led to significant improvement
and geriatric assessment – the program is completed within 2–4
in muscle strength of the lower limb when compared with the
weeks leading up to surgery.
effects from each intervention alone (77). In older adults with
T2DM, a multimodal training intervention, comprising of
personalized RET, nutritional counselling and general health Expert commentary: a call to action
counselling demonstrated improvements in muscle health (78).
Guidelines have recommended such combined approaches To optimize muscle health in older adults, improvements in
for the management and prevention of sarcopenia, including awareness, diagnosis and management across the continuum
the recently published Singapore Clinical Practice Guidelines of care is imperative. A paradigm shift is required where
for Sarcopenia (49, 68, 69). It is however important to ensure muscle health is seen as critical to good health, not only in
that older adults who exercise have adequate energy and avoiding adverse short term outcomes, but also in enabling
protein intake to maintain body weight and maintain/improve and maintaining independent living for as long as possible and
muscle mass (69). The AWGS Expert Consensus recommends leading to high quality and meaningful life. In this context, we
a combined approach using nutrition and resistance exercise have provided several key priorities and potential actions for
interventions in a tailored and individualized manner for best adoption within routine clinical care, with the ultimate goal of
outcomes (68). Recommended follow-up measures to assess improving outcomes for patients.
response to interventions include nutritional, anthropometric,
muscle health, functional, and HRQoL outcomes (68). Increasing awareness of the adverse clinical impact
of sarcopenia
Prehabilitation for patients with sarcopenia
undergoing surgery Key priorities for adoption of sarcopenia diagnosis and
management initially require the recognition by both HCPs
Major surgical procedures can substantially reduce and the public of the importance of muscle health and the
physiological and functional capacity, and the associated recognition of the impact sarcopenia can have. However, the
recovery process can lead to muscle atrophy and deterioration concept of sarcopenia is not well recognized nor understood
(79). As such, addressing sarcopenia prior to surgery through by either (85). Only half of HCPs across five continents
prehabilitation may help prepare individuals for their surgery involved in the care of older adults with musculoskeletal
by improving the functional capacity to tolerate stress from conditions measure at least one of the three domains of
surgery thereby reducing complications and improving recovery muscle mass, muscle strength, or physical performance in
(79). Studies assessing benefits of exercise and nutritional their clinical practice (86). Issues identified included a lack of
interventions are typically conducted over a long duration standardization in the assessment tool and protocol, leading to
(≥ 10 weeks) and yet, the lead up to major surgery is often difficulty in implementation and comparing results. In a study
only a few weeks long. There is thus a need for further study of Australian and New Zealand and Dutch HCPs, barriers
evaluating interventions that are impactful within a short to identification of sarcopenia included lack of awareness
intervention duration. The HEROS study (NCT05344313) is an and knowledge, with engaging in continuous professional
ongoing study assessing the effect of ONS with HMB and 2–4 development to acquire up-to-date knowledge suggested as a
weeks RET prehabilitation on muscle quality in patients with means to overcome this issue (22, 23). Limitations in awareness
sarcopenia undergoing surgery in Singapore; the outcome of of the health impact of sarcopenia by HCPs may be addressed,
this study will provide data on the optimal type and duration of at least in part, through professional education and training. For
intervention for this patient population. instance, provision of training, webinars, awareness programs,
Prehabilitation involves a multimodal approach and ‘toolkits’ comprising scientific information and illustrations
encompassing physical exercises, nutritional optimization and for HCPs should be prioritized to explain assessment of muscle
psychological support (79). Prehabilitation physical exercises strength, muscle mass, and physical performance, and in
aim to improve aerobic capacity and develop lean muscle mass, prevention and management, as well as the differences in
international guidelines and what is required for the local
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population across the continuum of care. should also include understanding differences in cut-offs or
Patient awareness and knowledge is of utmost importance measurement criteria relevant to the local population based
to improve muscle health and prevent sarcopenia, as ensuring on available diagnostic tools. Newer technologies, such as
adequate nutrition intake and regular RET requires patient ultrasound, need to be tested regarding their feasibility for
active efforts. However, patient’s lack of knowledge and poor/ sarcopenia diagnosis (95).
different understanding of sarcopenia (24, 85, 87) necessitates Population-specific data from a large and continuous
improving their awareness regarding the importance of database of muscle health measures (e.g., grip strength, knee
muscle health, which can be done through health promotion extensor strength, calf circumference, gait speed and 5-times
advertisements, campaigns, and public forums. Promoting Chair Stand Test) in younger adults would also help establish
awareness and self-assessment of muscle health among older appropriate cut-offs for poor muscle health in older adults.
patients can be explored using simple-to-execute tests such as
the 5-times Chair Stand Test (47), or through the use of mobile Establishing the optimal management of sarcopenia
apps to screen for nutritional status and muscle health (88).
HCPs should also be relied upon to implement educational The pillars of improving muscle health in older individuals
strategies for patients, families and caregivers; this may include are nutritional interventions and RET, delivered in an integrated
verbal/written advice and plain-language resources on muscle and tailored manner (47, 49, 68, 96). Although maintenance
health, nutrition and physical activity (2). Furthermore, patients or improvement in both muscle mass and function should be
can be encouraged to ask questions to their HCPs. the ultimate goal of sarcopenia management, all interventions
With limited resources, it may be difficult to invest in must at least demonstrate improvements in nutritional status
measuring muscle health. However, because muscle health has and muscle mass. Studies have shown that individuals with
multiple ramifications including falls prevention, reduction in an energy deficient diet have a measurable reduction in their
disability and mortality from falls-related trauma, and decreases muscle protein synthesis rate (97). In a glycogen-depleted
in disability and dependency, investing in measuring muscle state, studies have also shown a doubling rate of muscle protein
health will ultimately lead to reduced healthcare spending catabolism during increased physical activity (98). As such,
(89, 90) and higher HRQoL (91). This benefit of measuring identifying and treating any underlying concomitant protein
muscle health should be supported by high-quality population and energy malnutrition is necessary before putting older adults
health and health economics studies to provide an evidence into RET regimen. Once good nutritional health is achieved and
base supporting the projected improvements in population muscle strength returned to normative values, increased muscle
health and reduction in healthcare costs. This would require an mass and quality can be additional outcome measures.
increase in the scope of research, such as grants for capability Management strategies should be tailored to each patient,
developments and validation, and through higher hospital according to underlying conditions (medical, physical and
management buy-in. Because muscle health also impacts psychological) and individual circumstances that may act as
bone health, cardiovascular health, and cognitive wellbeing barriers to the uptake and adherence to nutritional interventions
(92), incorporating muscle health as part of the current public and exercise regimen. Subsidies for nutritional interventions
health campaigns in these areas could minimize the costs of (e.g., ONS) and for exercise (e.g., ActiveSG gym membership)
establishing a public health campaign highlighting muscle could help encourage uptake by older patients. Specific
health (47). considerations regarding RET in older adults are also required,
as they have different needs and require more individualization
Improving identification and diagnosis of in terms of the training regimen as compared to young adults.
sarcopenia Older adults may also have more intense delayed onset muscle
soreness (DOMS) post-RET (99) and hence may require pre-
Early identification of patients at risk of sarcopenia is a key training counselling and post-training mitigation strategies, such
priority, to enable prevention and management strategies to be as allowing more recovery time and use of massage for relief
implemented in a timely manner and to improve outcomes (3). (100, 101).
Although computed tomography (CT) scanning for diagnosis As with improving awareness and diagnosis of sarcopenia
of sarcopenia may be costly, involves radiation, or may not in older adults, resources for provision of evidence-based
be easily accessible, there are surrogate measures and other interventions for muscle health in older adults are also
modalities which are cost effective and can be deployed in inadequate. Although global data is emerging of the
the clinical setting such as use of Bioelectric Impedance substantial downstream benefits if muscle health and nutrition
Assessment (BIA), calf circumference measurement, and use are managed, further good quality research is needed to
of 5-times Chair Stand Test for lower limb strength (93) or demonstrate that management of sarcopenia makes a difference,
as a surrogate measure of gait speed (94). These are now including in a value-driven healthcare system such as that
also supported by consensus guidelines (3). More precise in Singapore. Such provision of evidence-based data would
and clinically predictive tests for muscle mass such as the benefit from the sharing of resources and protocols, as well
deuterated creatine dilution test may become more accessible in as collaboration. Similarly, high quality, prospective outcome
the near future and further enhance our ability to diagnose poor measures built into intervention programs on nutritional,
muscle health (2). Training for HCPs in sarcopenia diagnosis muscle health, clinical, functional outcomes, and HRQoL are

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 STRENGTHENING MUSCLE HEALTH OF COMMUNITY-DWELLING OLDER ADULTS IN SINGAPORE

required, including among particular patient subgroups, such as A framework such as ‘Sustain and Spread’ (Figure 1) can
those with T2DM and post-operative patients, to fine tune the be used to steer organizational culture change (106). Local
interventions, leading to a virtuous circle. champions within healthcare institutions would help enable,
encourage and acknowledge the efforts in screening, assessment
Promoting lifelong commitment to physical activity and management of sarcopenia so that these are sustained and
for sarcopenia prevention embedded in daily practice. In this framework, once there is
initial implementation success, several strategies are employed
A commitment to muscle health requires a lifelong to sustain and spread the successful changes thereby leading to
dedication to physical activity participation. Considering the an overall culture change (106).
age spectrum through which sarcopenia presents, preventive Figure 1. The Sustain and Spread Framework for creating a
efforts need to be enhanced to slow or prevent sarcopenia in the culture change
middle-aged, or even among younger populations, particularly
if they have low skeletal muscle mass to begin with. With the
current emphasis on physical activity as the cornerstone of
health by the WHO (61, 102), the time is ripe to encourage and
facilitate lifelong commitment to physical activity, not only in
older adults but throughout the whole population starting from
childhood into adulthood.
Physical activity participation rates in the older population (>
60 years) are low in Singapore. In a 2015 Sports and Physical
Activity survey conducted in ~7500 households, it was reported
that about 58% of Singaporeans aged > 60 years engaged in
less than 3 days per week of leisure time physical activity or
exercise (103), which is less than the minimum guidelines
recommended by the WHO (150 minutes of moderate-intensity
physical activity per week) (61). A cross-sectional study of Reproduced from Figure 1, Laur C et al., published under the Creative Commons
multi-ethnic Asian aged ≥60 years in a Singapore public Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/) (106).

primary healthcare centre found that the physical activity of

older adults decreased with increasing age and those with Conclusion
employment were twice as likely to have sedentary behaviour
(104). More worryingly, ~76% of Singaporeans between the With the rapidly aging population in Singapore, muscle
ages of 40-59 years also did not meet the minimum guideline health is soon becoming a growing public health concern.
recommended by the WHO (103). These statistics indicate that Early identification of sarcopenia in at-risk older individuals
most middle-aged and older Singaporeans are not physically along with evidence-based interventions are key to prevent
active – these are alarming because they reflect a relatively and reverse the progression of sarcopenia. Therefore, urgent
uninformed population regarding healthy lifestyle practices. actions to increase awareness of muscle health and improve the
The term ‘physical activity’ is broad and includes recreational, diagnosis and management of sarcopenia across the continuum
occupational and travel activities. Exercise training is a subset of care are imperative (Figure 2). To achieve these, there is
of physical activity that aims to improve cardiorespiratory and a need for active dialogues and collaboration among various
muscular fitness beyond what can be achieved with routine stakeholders (HCPs, professional societies, patients and their
physical activity. The numbers for regular participation in support networks, and policy makers).
exercise training focusing on improving cardiorespiratory and
muscular fitness indicate poor uptake (105). Thus, there needs Acknowledgment: Medical writing support for this manuscript was provided by Tricia
Newell, PhD, from In Vivo Communications Pte Ltd.
to be a greater emphasis on improving public awareness and
uptake of exercise training. In other words, the quality of Funding: The development of this manuscript was supported by Abbott Laboratories
habitual physical activity matters – this should be part of the (Singapore) Pte Ltd., which was strictly limited to editorial support provided by the
medical writer (see acknowledgements). All authors did not receive any honorarium
education of the general public and HCPs. More should be from Abbott Laboratories (Singapore) Pte Ltd. for the preparation of this manuscript.
done at the policy level to improve organizational support at the Abbott Laboratories (Singapore) Pte Ltd. had no role in the preparation or approval of this
manuscript.
workplace to enhance uptake amongst young and middle-aged
individuals as the nation embraces healthier Singapore. Conflict of interest disclosures: AB Maier has received consultation fees from Nutricia
and Abbott Nutrition. STH Chew has received grant co-funding, travel grant and honoraria
from Abbott Nutrition. NC Tan is the site principal investigator of a clinical trial sponsored
Creating and sustaining culture change to by Abbott Nutrition. FHX Koh and J Goh have nothing to declare.

strengthen muscle health importance Open Access: This article is distributed under the terms of the Creative Commons
Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/),
which permits use, duplication, adaptation, distribution and reproduction in any medium
There is an urgent need for a change in the healthcare culture or format, as long as you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons license and indicate if changes were made.
to incorporate muscle health as part of routine clinical practice.

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JFA - Volume

Figure 2. A call to action. Key priorities for action to strengthen muscle health in Singapore

Abbreviations: BIA, bioelectric impedance assessment; HCPs, healthcare providers; ONS, oral nutrition supplement.

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