Media Release


The INDEPENDENCY Study awarded with a $4.7 million grant funding, aims to directly test real-world solutions across various healthcare settings to bring about evidence-based strategies to improve frailty and heart health of seniors.

Singapore, 13 September 2023 – As the population of Singapore ages, the number of people aged 65 years and over is expected to increase to over 900,000 in 20301, and frailty prevalence in Singapore is anticipated to rise. Recognising that frailty is associated with a higher risk of cardiovascular disease (CVD) morbidity and poor health outcomes in seniors2, researchers at National Heart Centre Singapore (NHCS) have embarked on numerous studies since 2014, to gain insights and better understand cardiac ageing and frailty. 

Discoveries from earlier studies on cardiac ageing
About 20% of senior adults in the cohorts were found to have physical frailty and heart ageing. Several discoveries were also established including (1) the cardio-sarcopenia syndrome – associations between weakening of skeletal muscle mass, function and heart structure3,4, (2) an association between the results of hand grip strength tests and cardiac function4, which suggested that early stages of frailty (‘prefrailty’) may pre-exist in older adults in the community even before they develop cardiovascular disease, and (3) the nutritional components that were associated with heart ageing5,6

These notable discoveries propelled the research team to launch a novel research study - ‘INDEPENDENCY’ Study to test real-world clinical strategies that are expected to delay the onset of cardiovascular disease in the older adults. 

Early interventions to improve frailty: Diet and Exercise
Funded by the Ministry of Health, Singapore (MOH) with a grant of $4.7 million grant that is supported by the National Research Foundation (NRF) and the Health Promotion Board (HPB), the ‘INDEPENDENCY’ study aims evaluate a suite of tools and clinical interventions in and across various healthcare settings, from major acute hospitals to community hospitals and general community outpatient clinics. 

A key novelty of the study is a specially curated 12-week meal plan and a specialised 6- or 12-week exercise programme, for suitable cardiac frail patients across various healthcare settings.

“Through the combination of diet and exercise regime, we aim to achieve optimal results of reducing age-related frailty and improving skeletal muscle health.  Capturing at-risk patients and implementation of frailty care across healthcare systems can be challenging. Therefore, our strategy is to enable frailty care at as many healthcare encounters as possible, from community, to outpatient clinics, to inpatient hospital settings, including community hospitals. Casting a wide net maximises opportunities to allow more patients to benefit from such programmes, reflecting real-world scenarios that our patients go through daily,” shared Associate Professor Angela Koh, Senior Consultant from the Department of Cardiology, NHCS, who leads the Cardiac Ageing and Cardiac Frailty Studies.

The research team led by Assoc Prof Koh, have been working closely with dietitians, hospital kitchen chefs and an independent caterer, to tailor diet plans in the form of ‘hearty bentos’ specifically for those at risk of frailty. The diet plans were devised based on biochemical studies of ageing research volunteers. Studies showed that volunteers with early signs of heart ageing had changes in pathways involving nitrogen5,6. Hence the foods served are rich in various nutrients which are important to support the biochemical pathways that are altered in patients with heart ageing. 

Through serving these curated meals to selected patients across the entire spectrum of healthcare, the team aims to tackle frailty across the entire healthcare spectrum and create awareness that food or diet is a modifiable risk factor for frailty. Patients who have been discharged to home and following up at the outpatient clinics, will continue to receive the hearty bentos at their homes.

As tackling the nitrogen problem requires both exercise (to ‘beef up’ muscle) as well as nutritional support, study volunteers are enrolled into specialised 6- or 12-week exercise programmes conducted by trained physiotherapists.

Participating institutions include NHCS, Changi General Hospital, Sengkang General Hospital, Singapore General Hospital, Alexandra Hospital and Jurong Community Hospital, as well as collaborators from Tan Tock Seng Hospital and National Healthcare Group Polyclinics. 

Technology to enhance continuity of frailty care
Under the INDEPENDENCY Study, the research team has also introduced a smart screening kiosk which is being piloted at NHCS. With a touch of a few buttons and self-help features, the kiosk measures the patient’s skeletal muscle mass, blood pressure and visceral fat, which are essential data to determine one’s cardiovascular health in conjunction with frailty. As more patients join the programme, the team aims to scale up frailty screening with the kiosk.

Assoc Prof Koh also shared that the team plans to develop a unique platform where patients across different healthcare settings may be easily identified for frailty interventions, with the goal of enhancing the continuity of frailty care as patients move between hospitals, rehabilitation, outpatient settings and the community. 

“Through the INDEPENDENCY Study, we strive to build upon the science of frailty and cardiovascular disease to bring about evidence-based strategies suitable for clinical implementation. We believe that change can be initiated within and beyond hospital settings particularly for lifestyle changes or interventions, which can potentially delay the onset of cardiovascular disease,” said Associate Professor Yeo Khung Keong, Chief Executive Officer and Senior Consultant, Department of Cardiology, NHCS. 

  1. Ministry of Health Frailty Strategy Policy Report. 
  2. Afilalo J, Alexander KP, Mack MJ, Maurer MS, Green P, Allen LA, Popma JJ, Ferrucci L, Forman DE. Frailty assessment in the cardiovascular care of older adults. J Am Coll Cardiol. 2014 Mar 4;63(8):747-62. doi: 10.1016/j.jacc.2013.09.070. Epub 2013 Nov 27. PMID: 24291279
  3. Research led by NHCS found a potential predictor of cardiac disease in the elderly: Discovery of ‘Cardio-Sarcopenia’ syndrome from heart muscle ageing - National Heart Centre Singapore.
  4. Keng, B. M. H., Gao, F., Teo, L. L. Y., Lim, W. S., Tan, R. S., Ruan, W., Ewe, S. H., Koh, W. P., & Koh, A.S. Associations between Skeletal Muscle and Myocardium in Aging: A Syndrome of “Cardio‐Sarcopenia”? Journal of the American Geriatrics Society, 67(12), 2568–2573. (2019) DOI: 10.1111/jgs.16132
  5. Gao F, Kovalik JP, Zhao X, Chow VJ, Chew H, Teo LL, Tan RS, Leng S, Ewe SH, Tan HC, Tan TY, Lee LS, Ching J, Keng BM, Zhong L, Koh WP and Koh AS. Exacerbation of cardiovascular ageing by diabetes mellitus and its associations with acyl-carnitines. Aging (Albany NY). 2021;13:14785-14805.
  6. Kovalik JP, Zhao X, Gao F, Leng S, Chow V, Chew H, Teo LLY, Tan RS, Ewe SH, Tan HC, Wee HN, Lee LS, Ching J, Keng BMH, Koh WP, Zhong L and Koh AS. Amino acid differences between diabetic older adults and non-diabetic older adults and their associations with cardiovascular function. J Mol Cell Cardiol. 2021;158:63-71. doi: 10.1016/j.yjmcc.2021.05.009.:63-71.