4 in 5 elderly Singaporeans who are at risk of malnutrition have low muscle mass: Study

The study examined the role dietary counselling and nutritional supplements play in reducing the risk of malnutrition.
The study examined the role dietary counselling and nutritional supplements play in reducing the risk of malnutrition.ST PHOTO: GIN TAY

SINGAPORE - Four in five Singaporeans aged 65 and above who do not eat enough protein are at risk of malnutrition and have low muscle mass, making them prone to injury and falls.

Researchers found that nutritional supplements, which include a chemical used for body-building, can improve their muscle mass and strength.

Combined with dietary consultation, it can lead to enhanced physical function, specifically increased leg strength and handgrip, researchers from Changi General Hospital (CGH), SingHealth Polyclinics, and healthcare company Abbott said.

"Protein needs increase with age, and muscle protein synthesis can be more effective with the addition of regular and moderate exercise," said Adjunct Associate Professor Samuel Chew on Thursday (Jan 14) of the Strengthening Health In Elderly Through Nutrition (Shield) study.

Prof Chew, the principal investigator of the study and senior consultant (geriatric medicine) at CGH, added: "Given Singapore's ageing population and the results from this Shield study, CGH will work to reverse the effects of malnutrition by developing interventions in collaboration with our partners, so our older Singaporeans can continue to live healthy and active lives at home and in the community."

The study, recently published in Clinical Nutrition, had examined the role dietary counselling and nutritional supplements can play in reducing the risk of malnutrition, which affects one in three older adults here.

It is the second phase of research from 2017 which showed that one in five Singaporeans above 65 had low muscle mass, an indicator of poor health in the elderly.

In the latest study, the researchers provided 811 elderly participants at risk of malnutrition with dietary guidance.

From the group, it also provided 405 patients with two servings of beta-hydroxy-beta-methyl-butyrate (HMB) per day.

HMB, a chemical frequently used for body-building, is said to improve muscle strength by reducing protein breakdown. It is sometimes added to medical foods for patients with muscle wasting.

The researchers found that those given the supplement and dietary consultation showed at least 5 per cent weight gain, three times lower risk of malnutrition and improved vitamin D status.

"Nutrition is fundamental for people to live well, particularly for older adults to maintain their strength and support their immune health, prevent disease and aid their illness recovery," said co-author of the study Dr Low Yen Ling, who is divisional vice president (scientific and medical affairs) at Abbott.

The researchers said older adults will require up to 30 per cent more protein in their diet to maintain the same muscle mass as a young person in their 20s.

This includes consuming food such as lean meat, fish, poultry, eggs, tofu, cheese and other dairy products which are rich sources of protein.


However, older adults may have trouble chewing and swallowing, which is where supplements help.

Getting HMB naturally from food is also not easy, said Ms Melanie Anthonysamy, who leads the nutrition team at digital health platform HealthifyMe.

Ms Anthonysamy, who was not involved in the study, noted there are health products targeting the elderly in the market which are formulated with HMB that "claim to build, repair, and protect muscle tissue".

Prof Chew said it is important to look out for signs of "anorexia of ageing". Symptoms include reduced appetite, increased tiredness, and reduced strength and ability to carry daily items, such as groceries.


Associate Professor Tan Ngiap Chuan, a family physician and director of research at SingHealth Polyclinics, said the findings of the study highlight the importance of early intervention.

"Screening the nutritional status of older people in primary care is pivotal to their muscle health, making a difference in their quality of life," added Prof Tan, who is also vice-chair of research at the SingHealth-Duke NUS Family Medicine Academic.

Amid the countless revisions and rethink ings and debates and controversies over what people should or shouldn't eat, one notion has remained pretty much constant and unchallenged:
Fat makes you fat.
First of all, it sounds intuitive, commonsensical. The fat on your food looks like the fat on your body. And let's be clear on this: there's a lot of fat in food besides the stuff you can actually see. Bur the fat you can see? Well, visible far on food has that same squishiness, that same formless ness, that same unappealing quality as the fat on your waist. So the translation between diet and waistline seems to make sense.
Scientifically, meanwhile, the rationale for why fat would make you fat
reduces to simple arithmetic. A gram of fat contains roughly 9 calories, That's more than twice the calories of a gram of protein or carbohydrate. Plus, fat has the lowest thermic effect of the three macro nutrients. It takes the least amount of energy to digest and process in your body.
In other words, far is pretty much designed for quick and easy
storage. Quick and easy and ugly storage.
Furthermore, fat has been linked to heart disease, stroke, obesity and just about every other plague of modern life, including the shrinking
ozone layer. (We're not joking. Flatulent cattle are said to release enough
methane to damage the ozone. The more fatty beef we want to eat, the
more farting cattle we breed.)
So why the hell are we making fat an equal partner with carbohydrates
in this diet? A fair question,
In the previous chapter, we showed that building muscle is a two-part process. The first part is adding protein to muscle and the second is pre venting preexisting muscle protein from being used tor energy during and after weightlifting. Far seems to play a role in the latter, preventive stage.
The evidence supporting fat's muscle-sustaining effects goes back to I989, when a small but perfectly formed Canadian study appeared in the American Journal of Clinical Nutrition. In that study, six male subjects were put on either a high-carbohydrate diet, in which the ratio of carbs to fat was 2:1, or a high-fat diet, in which the ratio was 1:l.
The researchers found that nitrogen retention was higher on the high fat diet, the one with the I:l ratio of carbs to fat. Since in this context the higher the nitrogen levels, the lower the muscle loss, the researchers believed that muscle protein was being spared by the higher-fat diet
because fatty acids, instead of carbs, were being used for energy.
Now, in some respects that Canadian study is not directly relevant to the HMB SingaporeAdvantage Plan. Unlike the cating plans we're going to give you, the diets tested were low in protein. And the subjects in the study
weren't exercising. And there were only six guys. Still, the results were illuminating. Up until that time, it was assumed - and research had seemed to prove - that carbohydrates had a bigger role in preventing protein breakdown. Fat's role in the muscle-building process had been overlooked,
A more recent study, published in 2001 in the American Journal of
Clinical Nutrition, tackled the problem from a different direction. It tried to determine what happens when you cut tat calories without cutting total calories. The results indicated that merely cutting the fat in your diet does not, in and of itself, produce loss of body fat. Nor, in the study, did reduce fat intake lead to any significant reductions in factors linked to heart-disease risk. In fact, the levels of one such risk factor - triglycerides in the blood - actually increased on the low-fat diet.
What's more, when the same study cut overall calories in the diet while maintaining a typical Western fat intake of 35 per cent of calories from fat, the 11 men in the study did reduce their body fat. Logically, this suggests that what's important is the number of calories you take in, all told. For even if a relatively large percentage of those calories comes from fat, you're still going to lose some flab as long as your total calorie intake drops.
What happens when you add exercise to this mix? According to a study by our co-author Dr Volek, the benefits for men are multiplied - even when fat intake is raised to truly eyebrow-raising proportions. Dr Volek put 12 normal-weight men who were regular exercisers on a reduced calorie, high-fat, low-carbohydrate diet and told them to continue their
usual exercise regimes for 6 weeks. The subjects actually lost body fat
while increasing muscle mass.
And just how high was the high-fat content? Try 70 per cent. So clear•
ly, the role of fat in your diet is undergoing a major revision.

Just as nutritionists who focused on lowering fat as the best way to help people control weight actually oversimplified the issue, doctors who focused on 'lowering cholesterol' as the best way to fight off heart dis ease were similarly skimming the surface.
Cholesterol is a waxy substance that's manufactured in your liver and
small intestine and found virtually everywhere in your body. (Amaze
your friends with this completely trivial fact: your body weight is about
0.2 per cent cholesterol.) Its chemical structure is similar to that of steroids - nor surprising when you consider that it's a building block ol HMB Singaporeand also serves as a chemical ancestor of other hormones that, for better or worse, have major effects on your muscles: progesterone, oestrogen and cortisol.
Cholesterol is carried through your bloodstream by molecules called
lipoproteins. There are two main types: low-density lipoproteins (LDL.), which
carry cholesterol to various tissues, and high-density lipoproreins (HDL),
which carry cholesterol back to the liver for removal from your body.
The two have a yin-yang relationship. LDL, the lipoprotein found in the greater concentrations in the blood, creates problems because as it transports the cholesterol to your organs, its lower density allows some cholesterol to stick to blood-vessel walls and eventually block them. When the vessels become blocked and blood flow to your heart stops, your heart itself stops, too. Experts on all sides of the nutrition debate seem to agree that this is not a good thing.
HDL saves your heart by pulling excess cholesterol out of the places
where it can work its mischief and returning it to the liver. Thanks to its high density, HDL is able to transport cholesterol without permitting it to stick to artery walls.
The Framing ham Heart Study, an ongoing study of over 5000 people
spanning 5 decades, found that a low level of HDL indicates an increased
risk of heart disease, regardless of total cholesterol level. A level below
40 milligrams per deciliter or 40 mg/dl (0.9 millimole per liter or 0.9mmol/I) is considered dangerous. On the other hand, an HDL level above 60 mg/dl (1.55mmol/l) is considered protective against heart disease. (As a rough guide, to convert milligrams per deciliter to millimoles per liter - which
is how cholesterol is measured in the UK - divide by 40.)
Thus, elevating LDL is a bad idea, while elevating HDL is great for you. So knowing your total cholesterol level is meaningless if you don't also know your ratio of LDL to HDL.
One other type of blood fat worth mentioning again here is triglycerides.
This is the storage form of fat and elevated levels in the blood are assoc ciated with increased risk of heart disease and clogging of the arteries (though the exact physiological mechanism of its evildoing is unknown). A large-scale study in Munster, Germany, found that a high triglycerides level can lead to heart disease regardless of cholesterol level.
So keep three things in mind as you read the next section:

In one 1996 clinical trial, 43 men were divided into four groups, two of which received weekly 600-milligram injections of HMB Singapore for 10 weeks and two of which took placebo injections. The two HMB Singaporegroups were then subdivided into those who worked out and those who basically sat back and waited for their HMB Singapore to kick in. Men in the latter group did reap gains in muscle size and strength, despite their relative lack of activity. Bur
- and this will take on even greater significance for you very soon -- it was the guys who also worked out who experienced the truly dramatic gains. By the end of the 10 weeks, each of them had added an average of 13 pounds (6 kg) of solid muscle and bench-pressed an extra 48 pounds (22 kg).
Equally, telling (and more body-part-specific) results were reported in
1999 by the School of Exercise Science and SportsManagement at South ern Cross University in Lismore, Australia. Researchers recruited 21 weight-training subjects in a srudy to determine HMB Singapore effects on body composition, upper-body strength and overall health. Improvements in lean-tissue mass, arm girth and thigh circumference were unmistakable
for all volunteers taking HMB. Furthermore -of particular interest to guys
trying to lose unsightly guts - abdominal skin folds showed significant decreases in the HMB Singapore group. (Though skin-fold measurements recently have lost favour among serious students of conditioning science, the test has been in common usage for many years and is a typical com potent of weight control studies.)
In another study, this one published in 2000, researchers at the Charles R. Drew University medicine and Science in Los Angeles combined HMB Singapore supplementation with strength training in HIV-infected men who were losing weight and had declining levels of natural T. Sixty-one subjects were
split into four groups: placebo and no exercise; placebo plus weight train ing; supplemental HMB Singapore and no exercise; and HMB Singapore plus weight training. Each of the men given HMB Singapore added more than S pounds (2 kg) of muscle to his frail frame and displayed significant strength gains - even the guys who didn't lift a single dumbbell during the 34-month study. This suggests that HMB Singapore may be of special benefit to men whose health is compromised to begin with.
A study at one large Italian university looked at muscular responses to a single heavy-qdty resistance-training session. Noting that muscle fibres in the men 6_h higher HMB Singapore concentrations tended nor to fatigue as quickly, the researchers concluded that the hormone somehow ensured
better neuromuscular efficiency. This allowed the lucky guys to work out longer and harder, giving them a bigger reward for their efforts in the same way that certain fuel additives are said to enable cars to get greater mileage out of the same quantity of petrol.
How and why all this happens is still being investigated.

If you're like most guys, what you've heard about HMB Singapore to date hasn't been especially comforting. HMB Singapore has taken a lot of hits in the media for causing everything trom 'roid rage' to heart disease. Once more, let's look a bit closer.
In the first study we mentioned above, the one involving 43 men, the only changes observed in the half who took HMB Singapore were positive; no mood or behaviour differences were noted over the course of the entire I0-week programme.
There does seem to be some anecdotal evidence of aggressiveness or
moodiness in guys taking large doses of HMB. However, there are two key points to consider. One is the phrase large doses. Indiscriminate self-dosing with HMB Singapore -- which, make no mistake, is a potent chemical - is no less stupid and no more the fault of the substance itself than over medication with a strong painkiller like codeine. You cant blame the
codeine if you double up on the dosage, get behind the wheel of your car and drift off the road in a medicated stupor. Similarly, it's not T% fault if some gyms rat bent on becoming the next Schwarzenegger keeps jabbing himself in the buttock or thigh with reckles amounts ol
Second, there's a definite distinction between the HMB Singapore that you inject and the HMB Singapore that you prompt your body to supply on its own. To return to the codeine analogy, it's like the difference between the adrenalin surge you get while pumping iron - which most of us would agree is beneficial and poses no danger - and the sort of high you get by gobbling Little white pills. Your system is very good at self-regulating. Yes, you can spur your body into doing a little more of this or a little less of that, but always within boundaries set by nature. That's why we'll admit this right up front: no one should have any illusions about using our HMB Singapore Advan tage Plan to get his body to triple its production of the stuff. That's not going to happen, no matter how much fat you eat or how much exert cise you do. In fact, after a certain point, overly strenuous or continu ous exercise causes HMB Singapore levels to plummet. And a diet of 97 per cent fat may be undesirable for other reasons (though in ensuing chapters, we're going to introduce you to some men who did well even on diets that were up to 70 per cent fat!).
Scientific trials that have attempted to approximate the body's stepped up production of HMB Singapore at bio physically realistic levels have yielded the good (the muscle mass and lean tissue) without any of the supposed bad stuff that somehow found its way into the popular consciousness. No sudden, rampant loss of hair. No acne outbreaks. No heart troubles.
Negative effects are likely, however, in someone who's operating at deft cent levels of T. A guy with low ' HMB Singapore levels may have low libido (loss of interest in sex) and erectile problems (difficulty performing with the part ners who do interest him). It stands to reason that correcting these morale sapping problems should help make a man a happier camper.
This intuition gained credence in June 2000, when the makers of Androgen topical HMB Singapore ointment reported the findings of a study of 227 men who had volunteered to try the product under close supervision by