Dr Samuel Chew (right) putting a young Mr Nigel Chew through the moves in his “age suit”, which makes him feel like a frail old man. The straps stiffen his joints as in arthritis, a device under his feet creates a loss of sensation, and the goggles reduce his vision. Photos: Justin Loh

Even healthy old people who are independent, eat well, and have no diseases can have low muscle mass, which puts them at risk of falls. But this can often be reversed.

Mr Nigel Chew, 27, can usually bound up the stairs two or three steps at a go. But in an “age suit”, he moves like a frail old man.

The suit makes him feel what it is like to be aged.

Some 20kg to 30kg are piled on to simulate loss of muscle strength. Straps stiffen his joints and restrict his movements to show him what arthritis feels like. A device covers the soles of his feet to simulate a loss of sensation in his feet (as in the case of diabetes) so that he can hardly feel the ground he walks on.

Mr Chew, an executive with the Office of Innovation, Changi General Hospital (CGH), can now seriously empathise with the aged.

But he is lucky to be forewarned a long way in advance, so he can take steps to avoid some of the health problems associated with ageing. One of the main lessons he has learnt is the importance of building and maintaining muscle mass, which essentially means muscle strength.

Why muscle strength?

A recent local study has underlined the importance of having good muscle mass in old age. Low muscle mass (sarcopenia) not only affects overall health, but also makes walking difficult and puts a person at risk of debilitating falls.

While sarcopenia is evident in the frail and old, a surprising finding in the study was that it can also affect healthy seniors, said the study’s principal investigator, Dr Samuel Chew, Adjunct Assistant Professor, Department of Geriatric Medicine, CGH.

The study, called Strengthening Health in Elderly through Nutrition, was conducted by CGH, SingHealth Polyclinics, and Abbott to look at the impact of nutrition on the elderly.

Phase 1 of this two-part study looked at 400 healthy people in Singapore aged 65 and older, and found that despite their apparent health, one in five were at risk of low muscle strength. Women fared worse, with 25 per cent of them having low muscle mass compared to 15.5 per cent of men.

More than half the participants did not have enough vitamin D, which is provided by sunlight, and is important for muscle function, immunity, and bone health. The irony is that they live in Singapore, where there is sunshine all year long, so they should have been able to get sufficient vitamin D easily.

The significance of the findings is that the participants were not those usually at risk, such as patients who were elderly, with multiple chronic medical illnesses, or critically ill.

“This was a very unique group of participants. They were mostly healthy, independent people living in the community, who eat normally, and have no illnesses or past history of them,” said Dr Chew.

In Phase 2, which will be completed this year, 800 elderly participants at risk of being malnourished will be placed on oral nutritional supplements. Researchers want to find out how it will affect their nutritional status, and their rates of hospital admission and re-admission.

Losing muscle after 65

Given these findings, Dr Chew expects the population at large to have even higher rates of muscle mass loss than the study group. According to Dr Chew, 30 per cent of older people living in the community are at risk of malnutrition, and the risk of losing muscle mass increases exponentially by about 13 per cent yearly after age 65.

He said that there is a correlation between muscle and bone health, and gains to be had by targeting muscle health. “If you have very good muscle health, you cannot have weak bones. But if you have strong bones, you could still have very poor muscle health.

“Muscle health comes from activity to which the bone — a living matrix — responds. The more weight and pressure you put on the bone, the stronger it gets.”

Muscle mass is important not only for mobility. “Muscles also store amino acids needed for normal functioning of the body, and for recovery from illness, injury, and surgery.

“We need an ample amount of muscle mass. Having just enough may not be truly enough because it can be undermined by an illness, injury, or surgery to the point where a person can no longer walk. When lower-limb strength is absent, a person has a three to six times greater risk of falling than they normally do.”

However, it is often not too late to increase and maintain it. “The muscle mass status is modifiable,” Dr Chew added.

​Muscle medicine

The “medicine” for low muscle mass is exercise. This is where polyclinics can help patients, said Dr Tan Ngiap Chuan, Adjunct Associate Professor, Director of Research and Family Physician, SingHealth Polyclinics.

“Family physicians can provide guidance on a proper exercise programme, which could include calf-strengthening exercises. We want to standardise the way we measure muscle health, so that we can chart progress,” he said.

One easy way to gauge muscle health is to measure the circumference of the patient’s calves. If it is less than 33cm in men and 32cm in women, it reflects a higher risk of lower muscle mass. Exercise can increase the measurement.

Two simple exercises for muscle health:
• A single leg stand-up test: Sit down and lift one leg off the ground. Then try to stand upright with one leg balancing in the air. Hold the position for 3 seconds.

• Sit-to-stand for calf and thigh muscles: Stand up from an armless chair with your arms folded across your chest, then sit down. Do this 20 times at least twice a day.


Asian data helps

An important aspect of the study was getting Asian data about elderly nutrition. Professor Teo Eng Kiong, Chairman, Medical Board, CGH, said that such data has been lacking because the majority of previous data was Western-based.

He said that this data can now be used to establish Asian norms on nutritional standards for the Nutrition Health for Elderly Reference Centre at CGH, which aims to be a leader in nutrition health for the Asian elderly.

Dr Low Yen Ling, Director of Nutrition Research and Development at Abbott in the Asia Pacific, noted that the focus of current research is on “promoting better nutrition in elderly people living in the community, so that they can keep healthy, lead active lives, and not end up in the hospital”.

​How much protein to eat?

If an elderly person with weak muscles can get up from a sitting to a standing position, he can regain some of the lost strength through resistance training exercises and good nutrition. The latter means eating high-quality protein in appropriate amounts.

However, there is misinformation about protein intake, which leads to some older adults eating too little and avoiding certain proteins without any scientific basis. The recommendation is to consume 1.2g of protein for every 1kg of body weight, which translates to 72g of protein for someone weighing 60kg.

Older adults need to have at least three small meals a day that are rich in protein and energy, and avoid big dinners. This is advisable as smaller meals tend to be better tolerated, said Ms Magdalin Cheong, Deputy Director and Head of Dietetic and Food Services, CGH.

If their diets are balanced, vitamin and mineral supplements would not be necessary. “In the Asian context, for a normal person who’s eating everything, animal protein sources like chicken and fish are the best. For a vegetarian, we have to look at plant sources.”

The latter includes pulses, soy, and bean products, such as kidney beans and chickpeas. For those who can eat dairy products, milk and cheese are good alternatives to help increase protein intake.