Singapore’s longitudinal cohort study of midlife women reveals how muscle strength, visceral fat, and a simple blood test together offer powerful clues to future risk of diabetes, frailty, and physical decline after menopause
SINGAPORE — New research from the Integrated Women’s Health Programme (IWHP) at the National University Hospital (NUH) and the Yong Loo Lin School of Medicine, National University of Singapore (NUS Medicine), has uncovered new insights into how muscle strength and visceral fat, and their association with menopause, can potentially lead to downstream health impacts among women in Singapore, and how physical performance assessments and a simple blood test could help predict and prevent chronic conditions before they arise.
The first study, published in Diabetes, Obesity & Metabolism in October 20241, found that women with both weak muscle strength2 and high levels of visceral fat had the highest risk of developing prediabetes or type 2 diabetes. Their risk was 2.63 times higher than that of women who had normal muscle strength and lower fat levels.
Having just one of these conditions also increased risk, though to a lesser degree. The risk from having high visceral fat alone is 1.78 times higher. Among those with weak muscle strength, women with high visceral fat had a 2.84 times higher risk compared to those with low visceral fat.
Professor Yong Eu Leong, Head and Emeritus Consultant, Division of Benign Gynaecology, Department of Obstetrics and Gynaecology, NUH, and the lead of IWHP, said, “This finding validates our previous research that showed women should not just focus on weight loss, but also on building muscle strength through exercise for diabetes prevention.”
The study builds on an earlier 2022 IWHP paper3 that found midlife women with poor muscle strength had more than double the risk of diabetes compared to those with normal muscle strength. Women aged 45 to 69 years from Chinese, Malay and Indian ethnic groups were recruited between 2014 to 2016 from the NUH Women’s Clinic, now part of the National University Centre for Women and Children (NUWoC) – a specialist centre that aims to empower women, children, and their families to lead healthier lives. All participants were healthy at the time of recruitment. The team completed a second follow-up visit at the six-year mark from 2020 to 2023, and a third 12-year follow-up visit is scheduled to start in 2026.
In another recent study, published in Menopause in March 20254, the team found that a simple hospital blood test could help predict who is more likely to lose muscle mass and physical strength with age. Women with a lower ratio of creatinine to cystatin C (CCR), a marker derived from blood tests to check on skeletal muscle mass and kidney functions, had less muscle and walked more slowly later in life.
This suggested that CCR could be a useful early warning sign for sarcopenia and muscle decline, which may lead to falls, frailty, and reduced quality of life. As a potential screening tool which requires further investigation, CCR is simple, practical and low-cost compared to current methods of measuring muscle, like magnetic resonance imaging scans or strength tests, which are more expensive and time-consuming. CCR could be used to identify at-risk women early and recommend timely interventions.
A commentary by the study team, published in Annals in February 20255, further highlighted that menopause could lead to body changes in ways that are not always visible. Declining oestrogen during menopause contributes to increased visceral fat and reduced muscle mass – changes not captured by body mass index (BMI). These shifts are linked to greater risks of diabetes, hypertension, osteoporosis, and even early mortality.
The commentary also cited previous IWHP studies, including one published in 20176 which noted that weak hand grip strength was independently associated with increased risks of osteoporosis.
The commentary also cited previous IWHP studies, including one published in 20176 which noted that weak hand grip strength was independently associated with increased risks of osteoporosis.
Drawing on these findings, the IWHP researchers called this phenomenon the “Janus-like effect” — named after the Roman god of transitions — to describe the life-changing shift from the reproductive period to the post-menopausal stages of life.
“Beyond BMI and reduction of visceral obesity, exercises to improve physical performance and muscle strength have emerged as key lifestyle strategies to extend healthy lifespans for midlife Singaporean women,” said Prof Yong. “Targeted implementation programmes consisting of muscle strength exercises is beneficial for midlife women.”
The IWHP is an ongoing longitudinal study of midlife women in Singapore funded by the Singapore Ministry of Health through the National Medical Research Council (NMRC) Office, MOH Holdings Pte Ltd under the NMRC Clinician Scientist Award – Senior Investigator category (NMRC/CSASI/0010/2017, MOH-000670).
To download the PDF version of the media release, click here.
1Wong BWX, Tan DYZ, Li L-J, Yong E-L. Individual and combined effects of muscle strength and visceral adiposity on incident prediabetes and type 2 diabetes in a longitudinal cohort of midlife Asian women. Diabetes Obes Metab. 2025; 27(1): 155-164. doi:10.1111/dom.15995
2 Muscle strength Index (MSI) was measured using handgrip strength (HGS) and the five-time repeated chair stand (RCS) test, representing both upper and lower body muscle strength. Women with both poor HGS < 18 kg and/or prolonged RCS ≥12 s were considered to have a ‘poor’ MSI.
3 Wong, B. W. X., Thu, W. P. P., Chan, Y. H., Kramer, M. S., Logan, S., Cauley, J. A., & Yong, E.-L. (2022). The Associations between Upper and Lower Body Muscle Strength and Diabetes among Midlife Women. International Journal of Environmental Research and Public Health, 19(20), 13654. https://doi.org/10.3390/ijerph192013654
4 Tan, Darren Yuen Zhang BEng (Hons)1; Wong, Beverly Wen Xin MPH1; Shen, Liang PhD2; Li, Ling-Jun PhD1,3,4; Yong, Eu-Leong FRCOG, PhD1. Low creatinine to cystatin C ratio is associated with lower muscle volumes and poorer gait speeds in the longitudinal Integrated Women's Health Program cohort. Menopause ():10.1097/GME.0000000000002524, March 18, 2025. | DOI: 10.1097/GME.0000000000002524
5 Yong EL, Wong BWX, Tan DYZ. Beyond BMI: The Janus-like effect of muscle versus fat on midlife women's health. Ann Acad Med Singap. 2025 Feb 27;54(2):125-128. doi: 10.47102/annals-acadmedsg.2024278. PMID: 40071460.
6 Logan S, Thu WPP, Lay WK, et al. Chronic joint pain and handgrip strength correlates with osteoporosis in mid-life women: a Singaporean cohort. Osteoporos Int 2017;28:2633-43.
