Review
Sarcopenia in Asia: Consensus Report of the Asian Working Group for Sarcopenia

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Abstract

Sarcopenia, a newly recognized geriatric syndrome, is characterized by age-related decline of skeletal muscle plus low muscle strength and/or physical performance. Previous studies have confirmed the association of sarcopenia and adverse health outcomes, such as falls, disability, hospital admission, long term care placement, poorer quality of life, and mortality, which denotes the importance of sarcopenia in the health care for older people. Despite the clinical significance of sarcopenia, the operational definition of sarcopenia and standardized intervention programs are still lacking. It is generally agreed by the different working groups for sarcopenia in the world that sarcopenia should be defined through a combined approach of muscle mass and muscle quality, however, selecting appropriate diagnostic cutoff values for all the measurements in Asian populations is challenging. Asia is a rapidly aging region with a huge population, so the impact of sarcopenia to this region is estimated to be huge as well. Asian Working Group for Sarcopenia (AWGS) aimed to promote sarcopenia research in Asia, and we collected the best available evidences of sarcopenia researches from Asian countries to establish the consensus for sarcopenia diagnosis. AWGS has agreed with the previous reports that sarcopenia should be described as low muscle mass plus low muscle strength and/or low physical performance, and we also recommend outcome indicators for further researches, as well as the conditions that sarcopenia should be assessed. In addition to sarcopenia screening for community-dwelling older people, AWGS recommends sarcopenia assessment in certain clinical conditions and healthcare settings to facilitate implementing sarcopenia in clinical practice. Moreover, we also recommend cutoff values for muscle mass measurements (7.0 kg/m2 for men and 5.4 kg/m2 for women by using dual X-ray absorptiometry, and 7.0 kg/m2 for men and 5.7 kg/m2 for women by using bioimpedance analysis), handgrip strength (<26 kg for men and <18 kg for women), and usual gait speed (<0.8 m/s). However, a number of challenges remained to be solved in the future. Asia is made up of a great number of ethnicities. The majority of currently available studies have been published from eastern Asia, therefore, more studies of sarcopenia in south, southeastern, and western Asia should be promoted. On the other hand, most Asian studies have been conducted in a cross-sectional design and few longitudinal studies have not necessarily collected the commonly used outcome indicators as other reports from Western countries. Nevertheless, the AWGS consensus report is believed to promote more Asian sarcopenia research, and most important of all, to focus on sarcopenia intervention studies and the implementation of sarcopenia in clinical practice to improve health care outcomes of older people in the communities and the healthcare settings in Asia.

Section snippets

Diagnosis of Sarcopenia and Its Impact to Asia

Asia is a huge and densely populated continent with a wide range of ethnicities, cultural, social, religious backgrounds, and lifestyles. Because of the rapid population aging and the population size, the impact of sarcopenia in Asia may be stronger than in other continents. However, the status of population aging and economic development varies extensively in different Asian countries. Therefore, developing a consensus for sarcopenia diagnosis and clinical approaches based on available

Strategy for Sarcopenia Screening and Assessment

In principle, AWGS followed the diagnostic approach of EWGSOP, and we added some Asian perspectives in sarcopenia diagnosis and research. In the previous studies from Western countries, the prevalence of sarcopenia in older people was around 20% among people aged 65 years and older and may reach 50%–60% in octogenarians.34 EWGSOP recommends routine screening for sarcopenia among community-dwelling people aged 65 years and older. On the other hand, the International Working Group on Sarcopenia

Suggested Outcome Indicators in Sarcopenia Research

The EWGSOP definition suggests using physical performance, muscle strength, and muscle mass as the primary treatment outcome indicators for sarcopenia intervention trials, whereas activities of daily living, quality of life, metabolic and biochemical markers, inflammatory markers, global impression of change by subject or physician, falls, admission to nursing home or hospital, social support, and mortality as secondary outcome indicators.33 While most epidemiologic studies in sarcopenia

Assessment Techniques and Suggested Cutoff Values

Assessment of sarcopenia in Asian populations presents a great challenge because of the lack of outcome-based studies. However, determining appropriate cutoff values for sarcopenia diagnosis in Asia is critical to promote further sarcopenia research and treatment in Asia. Consequently, AWGS focused on the best available evidence to determine cutoff values for the diagnosis of sarcopenia in Asia. If, however, no outcome-based data are available, AWGS would recommend standardized approaches for

Muscle Mass

EWGSOP recommends DXA, computed tomography (CT), magnetic resonance imaging (MRI), and bioimpedance analysis (BIA) for sarcopenia research. Currently, the precision of DXA, CT, and MRI has been well recognized, but the precision of BIA in measuring muscle mass is controversial. BIA was developed to estimate the volume of body fat and lean body mass, but not appendicular muscle mass. Although the accuracy of BIA in sarcopenia diagnosis has been validated,39, 40, 41 it is heavily dependent on the

Muscle Strength

Measuring handgrip strength is considered a feasible and convenient measure of muscle strength because of cost, availability, ease of use, and its association with leg strength. Wu et al49 presented the norm of handgrip strength in Taiwan, which disclosed that the mean grip strength of the study sample in Taiwan was significantly lower (male 25%, female 27%) than consolidated norms derived from largely Caucasian populations. Although some papers published in Taiwan using this adjusted cutoff

Physical Performance

A wide range of tests for physical performance are recommended in EWGSOP criteria, including the Short Physical Performance Battery (SPPB), usual gait speed, the 6-minute walk test, the stair climb power test, and the timed-up-and-go test (TUG).51 Timed usual gait is highly predictive for the onset of disability,52 and other adverse health events like severe mobility limitation and mortality.53 TUG is an assessment of ambulation and dynamic balance. Poorer TUG has been demonstrated to be

Therapeutic Implications

Physical activities, including aerobics, endurance exercise,57 and resistance exercise training58, 59 have been demonstrated to significantly increase muscle mass and strength in sarcopenic older people. Although the recommended frequency of exercise training to improve muscle strength and functional performance has been shown,60 a consensus has not yet been reached concerning the content of the prescribed exercise and the most optimal frequency and intensity. Inappropriate exercise training in

Future Challenge and Conclusion

Sarcopenia significantly impacts daily activities, functional status, disability, and quality of life in older populations. Although Asian populations are rapidly ageing, from the clinical practice or public health points of view, the understanding of and preparation for sarcopenia remain inadequate. Hence, this consensus collected as many Asian studies as possible and offers a working diagnosis of sarcopenia for Asian people. The main aims of AWGS were to promote sarcopenia research in Asian

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