Sarcopenia


Written by Harriet Smith, RD. Peer-reviewed by Clare Thornton-Wood, RD.

We have gathered relevant information and resources on a variety of disease areas to support healthcare professionals.

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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

 

Criterion Criterions Met Diagnostic Outcome
1. Low skeletal muscle strength 1 Probable sarcopenia
2. Low skeletal muscle quality or quantity 1 and 2 Confirmed sarcopenia
3. Low physical performance 1, 2, and 3 Severe sarcopenia

 

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.

 

Variable Validated Tool/Test Practicalities in a Clinical Setting
Case finding (i.e. identifying those at risk)

SARC-Fquestionnaire

Ishii screening tool

SARC-F is a simple, easy, and rapid screening tool which could form part of a dietetic assessment

It has been suggested that SARC-F may not be appropriate for use in community-dwelling adults8

. The Ishii screening tool could be a suitable alternative.

Skeletal muscle strength

Handgrip strength (HGS)

Chair stand test (CST)

Muscle function reacts early to nutritional deprivation; HGS (measured using a hand dynamometer) is a useful marker of muscle function and nutritional status in a clinical setting.9

The CST strength is a simple way to access the strength of leg muscles. The CST measures the amount of time needed for a patient to rise five times from a seated position without using their arms3

 

Skeletal muscle quality or quantity

Appendicular skeletal muscle mass (ASMM) by Dual-energy X-ray absorptiometry (DXA)

Whole-body skeletal muscle mass or ASMM predicted by Bioelectrical impedance analysis (BIA)

Lumbar muscle cross-sectional area by CT or MRI

 

These tools and tests may not be readily available in NHS clinical establishments

BIA machines are sometimes used in research settings and/or private practice. However, BIA may not be a suitable measurement for someone with restricted mobility as it requires them to stand on the machine unsupported

 
 

Physical performance

Gait speed

Short physical performance battery (SPPB)

Timed-up-and-go test (TUG)

400-metre walk

 

Gait speed is a quick, safe and highly reliable test for sarcopenia. It involves timing how long it takes the patient to walk a distance of four metres.3

For the TUG test, the participant is asked to rise from the chair, walk a distance of 3 metres, return, and sit down again3

 

 

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

 

Click Here to Find Out More About AYMES Nutrition

 

References:

1. Cruz-Jentoft AJ, Bahat G, Bauer J, Boirie Y, Bruyère O, Cederholm T, et al. Sarcopenia: Revised European consensus on definition and diagnosis. Age and Ageing. 2019.

2. Santilli V, Bernetti A, Mangone M, Paoloni M. Clinical definition of sarcopenia. Clinical Cases in Mineral and Bone Metabolism. 2014.

3. Cruz-Jentoft AJ, Landi F, Schneider SM, Zúñiga C, Arai H, Boirie Y, et al. Prevalence of and interventions for sarcopenia in ageing adults: A systematic review. Report of the International Sarcopenia Initiative (EWGSOP and IWGS). Age Ageing. 2014.

4. 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.

5. Morishita S. Prevalence of Sarcopenia in Cancer Patients: Review and Future Directions. Int J Phys Med Rehabil. 2016.

6. Sayer AA, Syddall H, Martin H et al. The developmental origins of sarcopenia. J Nutr Health Aging 2008; 12: 427–32.

7. Dodds R, Denison HJ, Ntani G, Cooper R, Cooper C, Sayer AA, et al. Birth weight and muscle strength: A systematic review and meta-analysis. Journal of Nutrition, Health and Aging. 2012.

8. Yang M, Hu X, Xie L, Zhang L, Zhou J, Lin J, et al. SARC-F for sarcopenia screening in community-dwelling older adults Are 3 items enough? Med (United States). 2018;

9. Norman K, Stobäus N, Gonzalez MC, Schulzke JD, Pirlich M. Hand grip strength: Outcome predictor and marker of nutritional status. Vol. 30, Clinical Nutrition. 2011. p. 135–42.

10. Tanimoto Y, Watanabe M, Sun W, Tanimoto K, Shishikura K, Sugiura Y, et al. Association of sarcopenia with functional decline in community-dwelling elderly subjects in Japan. Geriatr Gerontol Int. 2013.

11. Kim M, Won CW. Sarcopenia is associated with cognitive impairment mainly due to slow gait speed: Results from the Korean frailty and aging cohort study (KFACS). Int J Environ Res Public Health. 2019.

12. Bischoff-Ferrari HA, Orav JE, Kanis JA et al. Comparative performance of current definitions of sarcopenia against the prospective incidence of falls among community-dwelling seniors age 65 and older. Osteoporos Int 2015; 26: 2793–802.

13. Malmstrom TK, Miller DK, Simonsick EM et al. SARC-F: a symptom score to predict persons with sarcopenia at risk for poor functional outcomes. J Cachexia Sarcopenia Muscle 2016; 7: 28–36.

14. Bahat G, Ilhan B. Sarcopenia and the cardiometabolic syndrome: a narrative review. Eur Geriatr Med 2016; 6: 220–23.

15. Bone AE, Hepgul N, Kon S et al. Sarcopenia and frailty in chronic respiratory disease. Chron Respir Dis 2017; 14: 85–99.

16. Beaudart C, Biver E, Reginster JY et al. Validation of the SarQoL(R), a specific health-related quality of life questionnaire for Sarcopenia. J Cachexia Sarcopenia Muscle 2017; 8: 238–44.

17. Liu P, Hao Q, Hai S, Wang H, Cao L, Dong B. Sarcopenia as a predictor of all-cause mortality among community-dwelling older people: A systematic review and meta-analysis. Maturitas. 2017.

18. Tan BHL, Brammer K, Randhawa N, Welch NT, Parsons SL, James EJ, et al. Sarcopenia is associated with toxicity in patients undergoing neoadjuvant chemotherapy for oesophago-gastric cancer. Eur J Surg Oncol. 2015.

19. Morishita S. Prevalence of Sarcopenia in Cancer Patients: Review and Future Directions. Int J Phys Med Rehabil. 2016.

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.

21. Antunes AC, Araújo DA, Veríssimo MT, Amaral TF. Sarcopenia and hospitalisation costs in older adults: a cross-sectional study. Nutr Diet. 2017.

22. Steffl M, Sima J, Shiells K et al. The increase in health care costs associated with muscle weakness in older people without long-term illnesses in the Czech Republic: results from the Survey of Health, Ageing and Retirement in Europe (SHARE). Clin Interv Aging 2017; 12: 2003–07.

23. Cruz-Jentoft AJ, Kiesswetter E, Drey M, Sieber CC. Nutrition, frailty, and sarcopenia. Aging Clin Exp Res. 2017.

24. Deutz NEP, Bauer JM, Barazzoni R, Biolo G, Boirie Y, Bosy-Westphal A, et al. Protein intake and exercise for optimal muscle function with aging: Recommendations from the ESPEN Expert Group. Clin Nutr. 2014.

25. Bauer J, Biolo G, Cederholm T, Cesari M, Cruz-Jentoft AJ, Morley JE, et al. Evidence-based recommendations for optimal dietary protein intake in older people: A position paper from the prot-age study group. J Am Med Dir Assoc. 2013.

26. Tieland M, van de Rest O, Dirks ML, van der Zwaluw N, Mensink M, van Loon LJC, et al. Protein Supplementation Improves Physical Performance in Frail Elderly People: A Randomized, Double-Blind, Placebo-Controlled Trial. J Am Med Dir Assoc. 2012.

27. Welch AA. Nutritional influences on age-related skeletal muscle loss. Proc Nutr Soc. 2014.

28. Zhou J, Huang P, Liu P, Hao Q, Chen S, Dong B, et al. Association of vitamin D deficiency and frailty: A systematic review and meta-analysis. Maturitas. 2016.

29. Beaudart C, Buckinx F, Rabenda V, Gillain S, Cavalier E, Slomian J, et al. The effects of vitamin D on skeletal muscle strength, muscle mass, and muscle power: A systematic review and meta-analysis of randomized controlled trials. Journal of Clinical Endocrinology and Metabolism. 2014.

30. SACN. Vitamin D and Health 2016. Sci Advis Comm Nutr. 2016.

31. Palacios C. The role of nutrients in bone health, from A to Z. Crit Rev Food Sci Nutr. 2006.