Sarcopenia

Section 1: Background Information

Sarcopenia

Sarcopenia is a progressive and generalised skeletal muscle disorder, characterised by low muscle strength, low muscle quality or quantity, and low physical performance.

It is associated with an increased likelihood of adverse outcomes such as falls, fractures, physical disability, and mortality.¹

Key Statistics

• By 60-70 years of age, 5-13% of people have sarcopenia; this rises to 11-50% in people older than 80 years of age²
• The prevalence of sarcopenia is up to 33% in community populations and 10% in acute hospital populations³
• Sarcopenia affects 15% of patients with stable COPD⁴
• The prevalence of sarcopenia amongst cancer patients ranges from 14-78.7%, depending on the cancer diagnosis⁵

Sarcopenia which is largely attributable to ageing is known as primary sarcopenia.⁶ Sarcopenia is considered ‘secondary’ when other causes (e.g. malignancy or malnutrition) are implicated.¹ It can be acute (lasting less than six months) or chronic (lasting ≥6 months). Acute sarcopenia is usually associated with an acute illness or injury, whereas chronic sarcopenia is associated with long-term, progressive conditions and increased risk of mortality.¹

Signs and Symptoms

Common signs and symptoms of sarcopenia include:¹

• Falls and fractures
• Slow walking speed
• Generalised weakness
• Fatigue
• Weight loss/muscle wasting
• Difficulty performing normal activities of daily life
• Functional decline
• Cognitive impairment

Aetiology

The aetiology of sarcopenia is largely multifactorial.

Potential causes of sarcopenia include:¹

• Age-related decline in skeletal muscle mass; a process which begins from around 50 years of age¹
• Genetics
• Hormonal changes
• Malabsorption
• Disease triggers (e.g. cancer, COPD)
• Environmental causes (e.g. reduced physical activity and/or dietary intake)
• Disability
• Sedentary lifestyle
• Inflammatory conditions (i.e. organ failure)
• Neurological disorders
• Low birth weight; a systematic review found a positive association between higher birth weight and greater muscle strength throughout the lifespan.⁷

Updated Definition and Diagnostic Criteria

In 2018 the European Working Group on Sarcopenia in Older People (EWGSOP2) updated its 2010 consensus recommendations; they developed an operational definition of sarcopenia (see below) to assist with diagnosis.¹

EWGSOP2 recommend using low skeletal muscle strength as the primary diagnostic parameter as it is the most reliable measure of muscle function.¹

A sarcopenia diagnosis is confirmed by the presence of low muscle strength and low muscle quantity/quality. When low muscle strength, low muscle quantity/quality, and low physical performance are all detected, sarcopenia is considered severe.

To learn more about these specific tests and tools, including defined cut-off points for sarcopenia, please click here.

In clinical practice, EWGSOP2 advises implementing the following diagnostic pathway:

1. Use of the SARC-F questionnaire to identify individuals with probable sarcopenia
2. Measurement of muscle strength using handgrip strength and/or chair stand tests*
3. Measurement of muscle mass/quality by DXA or BIA methods to confirm sarcopenia.
4. Measurement of physical performance using SPPB, TUG, or 400-metre walk tests to assess the severity of sarcopenia

*EWGSOP2 advises that steps 1 and 2 are sufficient to trigger an assessment of causes and start interventions in a clinical setting.

Section 2: The Impact of Sarcopenia

When left untreated sarcopenia has a significant impact on individuals, society, and the wider healthcare system.

On an individual level, sarcopenia is associated with:

• Functional decline and cognitive impairment in older adults.^{10, 11}
• Increased risk of falls and fractures.¹²
• Impaired ability to perform usual daily activities.¹³
• Cardiac disease.¹⁴
• Respiratory disease.¹⁵
• Reduced quality of life.¹⁶
• All-cause mortality.¹⁷

In patients living with cancer, sarcopenia is associated with treatment tolerance issues. For example, in patients undergoing neoadjuvant chemotherapy for oesophagogastric cancer, sarcopenia is a significant predictor of dose-limiting toxicity.¹⁸

Cancer patients with sarcopenia also have a lower quality of life, worsened fatigue, decreased physical function, and longer hospital stays relative to cancer patients without this disorder.¹⁹ Additionally, sarcopenia impairs function and health status in COPD patients.²⁰

On a wider level, sarcopenia is associated with increased hospital admissions and healthcare costs. A cross-sectional study of over 200 older adults found sarcopenia and low muscle strength at hospital admission were independently associated with increased hospital costs.²¹ A further study from the Czech Republic suggests that direct healthcare costs are 2-fold higher in patients with sarcopenia than those without.²²

Section 3: Nutritional Strategies for Sarcopenia

When treating or preventing sarcopenia, the aim is to minimise skeletal muscle loss and preserve muscle function through a combination of physical activity (which includes resistance exercise) and good nutrition.³

Beyond eating a healthy and balanced diet and maintaining adequate hydration, current dietary recommendations for the prevention and treatment of sarcopenia focus on protein and vitamin D.

Energy and Protein Requirements

Eating enough energy (calories) to maintain a healthy body mass index (BMI) is important for the prevention of malnutrition; a contributing factor in the pathogenesis of sarcopenia.²³ Similarly, ensuring an adequate intake of protein is important for preventing and treating sarcopenia and frailty.³

Guidelines from the European Society for Parenteral and Enteral Nutrition (ESPEN) and an international study group who reviewed dietary protein needs in aging (PROT-AGE) recommend increasing protein intake, through food-first techniques or supplementation, to 1.0-1.2 g/kg body weight/day (with even higher intakes in those with severe injury or illness) in older people.^{24, 25}

Below is a list of energy and protein-dense foods which could be included in an older person’s diet to increase calories and protein:

• Oily fish (i.e. salmon or mackerel)
• Lean meat and poultry
• Eggs
• Nuts and seeds
• Dairy products (i.e. cheese, milk, yoghurt, custard)
• Dried skimmed milk powder
• Soups fortified with milk powder or milk
• Smoothies made with milk or yoghurt
• Cakes and bars

In older adults who are unable to meet their nutritional requirements through an oral diet alone, high-energy, high-protein oral nutrition supplements may be useful for meeting energy and protein requirements. Increasing protein intake by 30g per day has been shown to improve physical performance in frail, community-dwelling older adults.^26>

What Does 30g Protein Look Like?

• Two chicken eggs and 125g Greek yoghurt and 30g cheddar cheese
• Two-thirds of a chicken breast fillet
• One fillet of salmon and 200mls whole milk
• One lamb chop and one-third of a can of baked beans

There is not enough evidence to make practice recommendations for essential amino acid supplementation.³

Vitamin D

Vitamin D plays an important role in bone and muscle strength and it may also have a protective role in reducing muscle loss.^27> Low levels of vitamin D are significantly associated with the risk of frailty.^28>

A systematic review and meta-analysis of randomised controlled trials found supplementing people with vitamin D had a small positive effect on muscle strength. The researchers found greater levels of sarcopenia in people who presented with a vitamin D deficiency (25-hydroxyvitamin D level < 30 nmol/L) or were aged 65 years or older.^29>

All UK adults, including those at increased risk of vitamin D deficiency, should consume a 10 microgram (400 IU) Vitamin D supplement daily from October to March.³⁰ People with very little or no sunlight exposure should consume 10 micrograms of vitamin D throughout the year. If a vitamin D deficiency is detected, higher dosage supplementation is recommended according to local prescribing guidance.

Other Nutrients

Other micronutrients such as calcium, magnesium, and phosphorus are known to play an important role in bone health.³¹ There is also some evidence that antioxidants such as vitamin C and vitamin E may help to prevent skeletal muscle loss. Thus, older adults should be encouraged to consume a healthy and balanced diet which provides the recommended daily amount for these micronutrients.

Multidisciplinary (MDT) Approach

Whilst this article has focused on the importance of nutritional strategies in the prevention/management of sarcopenia, it is important to highlight that other strategies such as tailored exercise programmes (delivered by a suitable qualified HCP) form an important part of a wider MDT approach.

Section 4: Useful Resources on Sarcopenia

• The Lancet - Sarcopenia
• Sarcopenia: European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People (2010).
• Sarcopenia: revised European consensus on definition and diagnosis (2019).
• Prevalence of and interventions for sarcopenia in ageing adults: a systematic review. Report of the International Sarcopenia Initiative (EWGSOP and IWGS) (2014).
• Protein intake and exercise for optimal muscle function with aging: Recommendations from the ESPEN Expert Group.
• Evidence-based recommendations for optimal dietary protein intake in older people: a position paper from the PROT-AGE Study Group.
• Nutritional influences on age-related skeletal muscle loss.
• Today’s Dietitian - Nutrition’s Role in Sarcopenia Prevention.

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20. Jones SE, Maddocks M, Kon SSC, Canavan JL, Nolan CM, Clark AL, et al. Sarcopenia in copd: Prevalence, clinical correlates and response to pulmonary rehabilitation. Thorax. 2015.

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