Letter to the editor: Case for validated instead of standard cut-offs for SARC-CalF

Association of possible sarcopenia with all-cause mortality in patients with solid cancer: A nationwide multicenter cohort study

OBJECTIVES

The concept of possible sarcopenia (PS) was recently introduced to enable timely intervention in settings without the technologies required to make a full diagnosis of sarcopenia. This study aimed to investigate the association between PS and all-cause mortality in patients with solid cancer.

DESIGN

Retrospective observational study.

SETTING AND PARTICIPANTS

13,736 patients with 16 types of solid cancer who were ≥18 years old.

MEASUREMENTS

The presence of both a low calf circumference (men <34 cm or women <33 cm) and low handgrip strength (men <28 kg or women <18 kg) was considered to indicate PS. Harrell's C-index was used to assess prognostic value and the association of PS with mortality was estimated by calculating multivariable-adjusted hazard ratios (HRs).

RESULTS

The study enrolled 7207 men and 6529 women (median age = 57.8 years). During a median follow-up of 43 months, 3150 deaths occurred. PS showed higher Harrell's C-index (0.549, 95%CI = [0.541, 0.557]) than the low calf circumference (0.541, 95%CI = [0.531, 0.551], P = 0.037) or low handgrip strength (0.542, 95%CI = [0.532, 0.552], P = 0.026). PS was associated with increased mortality risk in both univariate (HR = 1.587, 95%CI = [1.476, 1.708]) and multivariable-adjusted models (HR = 1.190, 95%CI = [1.094, 1.293]). Sensitivity analyses showed that the association of PS with mortality was robust in different covariate subgroups, which also held after excluding those patients who died within the first 3 months (HR = 1.162, 95%CI = [1.060, 1.273]), 6 months (HR = 1.150, 95%CI = [1.039, 1.274]) and 12 months (HR = 1.139, 95%CI = [1.002, 1.296]) after enrollment.

CONCLUSION

PS could independently and robustly predict all-cause mortality in patients with solid cancer. These findings imply the importance of including PS assessment in routine cancer care to provide significant prognostic information to help mitigate sarcopenia-related premature deaths.

The Impact of Sarcopenia Risk on Postoperative Walking Independence in Older Adults Undergoing Total Joint Arthroplasty

BACKGROUND AND PURPOSE

Sarcopenia is known to be associated with poor outcomes after arthroplasty; however, no study has reported the relationship between sarcopenia and postoperative walking independence. This study aimed to determine the impact of sarcopenia risk screening using the SARC-CalF questionnaire and calf circumference on the time to walk independently after total hip or knee arthroplasty in older patients.

METHODS

We included 599 nonobese patients aged 65 years and older who underwent unilateral and primary total hip or knee arthroplasty. Preoperative sarcopenia risk was assessed using the SARC-CalF or calf circumference. The outcome of this study was the time to independent walking after surgery; it was calculated as the number of days from the date of surgery to the date when the patient was able to walk independently. The association between preoperative sarcopenia risk and time to independent walking after surgery was analyzed using Kaplan-Meier curves and Cox proportional hazards models.

RESULTS

Among the 599 patients undergoing total joint arthroplasty, 175 (29.2%) were determined to be at risk of sarcopenia using SARC-CalF and 193 (32.2%) using calf circumference. The Kaplan-Meier curve showed that sarcopenia risk assessed by SARC-CalF or calf circumference was associated with a prolonged time to independent walking in patients undergoing hip arthroplasty (log-rank test, P < .001 and P < .001, respectively). In patients undergoing hip arthroplasty, the Cox proportional hazards model showed that SARC-CalF score of 11 points and greater or a calf circumference less than the cutoff was a risk factor for delayed time to independent walking (hazard ratios: 0.55 and 0.57, P < .001 and P = .001, respectively). There was no association between preoperative sarcopenia risk and postoperative time to independent walking in patients who underwent knee arthroplasty.

CONCLUSIONS

Sarcopenia screening tools, such as SARC-CalF or calf circumference, should be useful for planning postoperative rehabilitation in older adults scheduled for hip arthroplasty. However, the accuracy of SARC-CalF or calf circumference measurement in patients scheduled for knee arthroplasty may be low.

Brachial-Ankle Pulse Wave Velocity Mediates the Association between Increased Age and Risk of Sarcopenia among Chinese Patients with Type 2 Diabetes Mellitus

BACKGROUND AND AIMS

Arterial stiffness and sarcopenia are commonly seen in patients with type 2 diabetes mellitus (T2DM), and both are age-related diseases. However, few studies have addressed the causal relationship between age, arterial stiffness, and sarcopenia, especially in patients with T2DM. This study is aimed at investigating the relationship among age, arterial stiffness, and sarcopenia in patients with T2DM.

METHODS AND RESULTS

This cross-sectional study enrolled 557 inpatients with diabetes at the First Affiliated Hospital of Wenzhou Medical University, China, between June 2020 and July 2021. Patients who were diagnosed with T2DM and underwent examination of dual-energy X-ray absorptiometry, handgrip strength, 6-meter walk speed, and brachial-ankle pulse wave velocity (baPWV, a recognized indicator of arterial stiffness) were enrolled. A total of 447 patients were included. A dose-dependent relationship was found between age and sarcopenia. We also found a dose-dependent relationship between age and baPWV. Similarly, significant dose-dependent relationships were found across baPWV tertiles with higher prevalence of sarcopenia. Then, a mediation analysis was performed to explore the mediation effect of arterial stiffness on age-associated sarcopenia. We found that the prevalence of sarcopenia increased by 0.0115 (95% CI, 0.0028-0.0239) per 1 year increase in age by the mediation effect of baPWV and that the direct effect of aging on sarcopenia was 0.0441 (95% CI, 0.0101-0.0909) per 1 year older. baPWV mediated 20.5% of the positive relationship between increased age and the prevalence of sarcopenia.

CONCLUSIONS

Elevated baPWV partially mediates the association of age and sarcopenia among patients with T2DM.

Changes of sarcopenia case finding by different Asian Working Group for Sarcopenia in community indwelling middle-aged and old people

Sarcopenia is an emerging issue, but there is no universal consensus regarding its screening and diagnosis, especially regarding the influence of the Asian Working Group for Sarcopenia (AWGS) 2019 new definition on the prevalence of community-dwelling adults. To compare the prevalence of sarcopenia between the 2019 and 2014 definitions, a cross-sectional study including 606 normal nutritional status subjects (203 men/403 women; mean age 63.3 ± 10.0 years) was performed. Sarcopenic parameters, including calf circumference, grip strength, 6-m gait speed, and bioelectrical-impedance-analysis-derived skeletal mass index (SMI), were evaluated. According to the 2019 AWGS definition, the prevalence of possible sarcopenia and sarcopenia among community-dwelling adults was 7.4 and 2.8%, respectively. There were highly consistent findings regarding sarcopenia between the 2019 and 2014 AWGS definitions according to Cohen's kappa coefficient (0.668). However, the prevalence of possible sarcopenia according to 2014 and 2019 AWGS in males increased 7.9%; in contrast, sarcopenia decreased from 7.4 to 3.7% in females (p < 0.001). In conclusion, the AWGS 2019 definition is more convenient for sarcopenia case screening and remains considerably consistent in sarcopenia identification in community-dwelling adults in Taiwan. The discordance of possible sarcopenia and sarcopenia by sex is a concern.

Development of a risk prediction nomogram for sarcopenia in hemodialysis patients

Background

Sarcopenia is associated with various adverse outcomes in hemodialysis patients. However, current tools for assessing and diagnosing sarcopenia have limited applicability. In this study, we aimed to develop a simple and reliable nomogram to predict the risk of sarcopenia in hemodialysis patients that could assist physicians identify high-risk patients early.

Methods

A total of 615 patients undergoing hemodialysis at the First Affiliated Hospital College of Medicine Zhejiang University between March to June 2021 were included. They were randomly divided into either the development cohort (n = 369) or the validation cohort (n = 246). Multivariable logistic regression analysis was used to screen statistically significant variables for constructing the risk prediction nomogram for Sarcopenia. The line plots were drawn to evaluate the effectiveness of the nomogram in three aspects, namely differentiation, calibration, and clinical net benefit, and were further validated by the Bootstrap method.

Results

The study finally included five clinical factors to construct the nomogram, including age, C-reactive protein, serum phosphorus, body mass index, and mid-upper arm muscle circumference, and constructed a nomogram. The area under the ROC curve of the line chart model was 0.869, with a sensitivity and specificity of 77% sensitivity and 83%, the Youden index was 0.60, and the internal verification C-statistic was 0.783.

Conclusions

This study developed and validated a nomogram model to predict the risk of sarcopenia in hemodialysis patients, which can be used for early identification and timely intervention in high-risk groups.

Utility of SARC-F in daycare facilities for older people

AIM

SARC-F, a sarcopenia screening tool, has limited use but may be beneficial for detecting sarcopenia in frail older people. This study aimed to clarify the validity of the SARC-F questionnaire in older people.

METHODS

In this validation study, 74 (36 men; age, 81.9 ± 6.7 years, 38 women; age, 83 ± 6.2 years) community-dwelling older people who attended a daycare facility participated in our study. Participants completed the SARC-F and SARC-calf circumference (SARC-CalF) questionnaires, and their body composition, walk speed and grip strength were measured. Sarcopenia was determined using the Asian Working Group for Sarcopenia criteria, and the participants were divided into non-sarcopenia and sarcopenia groups. SARC-F and SARC-CalF scores were evaluated using receiver operating characteristic curve analysis for sarcopenia considering the area under the curve. Internal consistency was evaluated using Cronbach's alpha.

RESULTS

The prevalence of sarcopenia, defined by physical characteristics, was 60.0% in men and 48.1% in women. The area under the curve of the SARC-F for sarcopenia was 0.703 (95% confidence interval [CI]: 0.585-0.821, P = 0.001). Cronbach's alpha was 0.81, and the internal consistency was high. SARC-F had lower sensitivity (0.47; 95% CI: 0.31-0.64) but higher specificity (0.78; 95% CI: 0.60-0.89) than the sensitivity and specificity of SARC-CalF, respectively, and the sensitivity of SARC-F was higher than that reported in previous studies.

CONCLUSION

The SARC-F questionnaire is more sensitive in assessing sarcopenia in low-functioning populations and can be used as a screening tool for sarcopenia in long-term daycare facilities for older people rather than in community-based healthcare activities. Geriatr Gerontol Int 2022; ••: ••-••.

Development of a Simple and Practical Screening Tool for Detection of Sarcopenia in Older People: The Bushehr Elderly Health Program

Background: Sarcopenia is defined by the loss of muscle mass and function with a considerable prevalence which increases morbidity and mortality. We aimed to develop and validate a simple tool for screening of sarcopenia in Iranian older population.

Methods: In this study, we included 2,211 adults aged 60 years or older that participated in the stage II of Bushehr Elderly Health (BEH) program, a population-based prospective cohort study. We defined sarcopenia as reduced skeletal muscle strength plus low muscle mass. The study sample was divided into two parts; development set which were allocated to the development of the model (n = 1,499) and validation set (n = 712) were allocated to validation of the model.

Results: There were 22.9% of men and 23.2% women classified as having sarcopenia based on EWGSOP-2.After selection of variables, the final models named SarSA-Mod (Sarcopenia Scoring Assessment Models) were developed with area to under curves (AUC) of 0.82 (0.79–0.86) and 0.87 (0.84–0.90) in men and women, respectively. The final model included “age,” “weight,” and “calf circumference” in both sexes. The sensitivity and specificity and positive and negative predictive values for sarcopenia were 84.3, 76.0, 49.8, and 94.5% for women, 85.4, 64.8, 40.2, and 94.2% for men, respectively. The model performance was tested in the validation set with accuracy 91 and 84% among women and men, respectively.

Conclusions: Sarcopenia could be detected using SarSA-Mod, as a simple screening test with high accuracy among both sexes. Also, this screening test is valid, feasible, reliable and cost-effective compared to other tools.

Comparison of Diagnostic Performance of SARC-F and Its Two Modified Versions (SARC-CalF and SARC-F+EBM) in Community-Dwelling Older Adults from Poland

PURPOSE

Older adults should be routinely screened for sarcopenia, which threatens healthy, independent aging. The most popular screening tool is the SARC-F questionnaire. As its sensitivity is unsatisfactory, two modified versions of the questionnaire have been published: SARC-CalF (including calf circumference as an additional item) and SARC-F+EBM (assessing additionally age and Body Mass Index). The diagnostic performance of the three versions of the questionnaire has not been compared. The analysis aimed to assess the diagnostic value of SARC-F, SARC-CalF, and SARC-F+EBM questionnaires, and to compare their psychometric properties against two reference standards of sarcopenia diagnosis, ie, EWGSOP1 and modified EWGSOP2 criteria.

MATERIALS AND METHODS

We performed the sensitivity/specificity analysis and compared the overall diagnostic accuracy of SARC-F, SARC-CalF (31cm) (cut-off point 31 cm for both genders), SARC-CalF (33/34cm) (cut-off points: 33 cm for women and 34 cm for men), and SARC-F+EBM in 115 community-dwelling volunteers aged ≥ 65 yrs from Poland.

RESULTS

Depending on the version of the SARC-F questionnaire used, from 10.4% [SARC-CalF (31cm)] to 33.0% (SARC-F+EBM) were identified as having an increased risk of sarcopenia. Sarcopenia was identified in 17.4% by the EWGSOP1 criteria and in 13.9% by the modified EWGSOP2 criteria. With respect to the two reference standards used, the sensitivity of SARC-F, SARC-CalF (31cm), SARC-CalF (33/34cm), and SARC-F+EBM ranged 30.0-37.5%, 35.0-37.5%, 60.0-62.5%, 55.0% (the same value for both reference standards), respectively. The specificity ranged 85.3-85.9%, 93.9-94.7%, 88.4-86.9%, 70.7-71.6%, respectively. The AUC of SARC-F, SARC-CalF (31cm), SARC-CalF (33/34cm) and SARC-F+EBM ranged 0.644-0.693, 0.737-0.783, 0.767-0.804, 0.714-0.715, respectively.

CONCLUSION

The modified versions of SARC-F have better diagnostic performance as compared to the original questionnaire. Since an ideal screening tool should have reasonably high sensitivity and specificity, and an AUC value above 0.7, the SARC-CalF (33/34cm) seems to be the best screening tool for sarcopenia in community-dwelling older adults.

Comparison of four sarcopenia screening questionnaires in community-dwelling older adults from Poland using six sets of international diagnostic criteria of sarcopenia

INTRODUCTION

There are four screening sarcopenia questionnaires (SARC-F, SARC-CalF, MSRA-5, MSRA-7). To unambiguously determine which of them is the most effective tool in community-dwelling older adults, we performed a diagnostic accuracy study. The aim of the analysis was to assess the diagnostic values of SARC-F, SARC-CalF, MSRA-5, MSRA-7 and compare their psychometric properties against six criterion standards (EWGSOP1, EWGSOP2, FNIH, AWGS, IWGS, SCWD criteria).

MATERIALS AND METHODS

We included 100 community-dwelling volunteers aged ≥ 65yrs. The sensitivity/specificity analyses were performed. Receiver operating characteristic (ROC) curves and area under the ROC curves (AUC) were calculated to compare the overall diagnostic accuracy of the four questionnaires. Ideal screening tools should have reasonably high sensitivity and specificity, and an AUC value above 0.7.

RESULTS

With respect to the six criterion standards used, the sensitivity of SARC-F, SARC-CalF, MSRA-5, and MSRA-7 ranged 35.0-90.0%, 20.0-75.0%, 64.7-90.0%, 76.5-91.7%, respectively, whereas the specificity ranged 86.9-91.1%, 80.0-90.0%, 45.8-48.8%, 28.9-31.0% respectively. The AUCs of SARC-F, SARC-CalF, MSRA-5, and MSRA-7 ranged from 0.655-0.882, 0.711-0.874, 0.618-0.782 and 0.588-0.711 respectively. Only SARC-CalF had AUC >0.7 and <0.9 against the six criterion standards but obesity was a confounding factor, which may affect the diagnostic power of SARC-CalF. MSRA-7 had the smallest AUC of all the questionnaires and MSRA-5 had slightly larger AUC than MSRA-7.

CONCLUSION

Based on our analysis, the standard sarcopenia screening questionnaires deliver contradictory results in many practically occurring cases. It appears that SARC-CalF is an optimal choice for screening sarcopenia in community-dwelling older adults.

Asian Working Group for Sarcopenia: 2019 Consensus Update on Sarcopenia Diagnosis and Treatment

Clinical and research interest in sarcopenia has burgeoned internationally, Asia included. The Asian Working Group for Sarcopenia (AWGS) 2014 consensus defined sarcopenia as "age-related loss of muscle mass, plus low muscle strength, and/or low physical performance" and specified cutoffs for each diagnostic component; research in Asia consequently flourished, prompting this update. AWGS 2019 retains the previous definition of sarcopenia but revises the diagnostic algorithm, protocols, and some criteria: low muscle strength is defined as handgrip strength <28 kg for men and <18 kg for women; criteria for low physical performance are 6-m walk <1.0 m/s, Short Physical Performance Battery score ≤9, or 5-time chair stand test ≥12 seconds. AWGS 2019 retains the original cutoffs for height-adjusted muscle mass: dual-energy X-ray absorptiometry, <7.0 kg/m2 in men and <5.4 kg/m2 in women; and bioimpedance, <7.0 kg/m2 in men and <5.7 kg/m2 in women. In addition, the AWGS 2019 update proposes separate algorithms for community vs hospital settings, which both begin by screening either calf circumference (<34 cm in men, <33 cm in women), SARC-F (≥4), or SARC-CalF (≥11), to facilitate earlier identification of people at risk for sarcopenia. Although skeletal muscle strength and mass are both still considered fundamental to a definitive clinical diagnosis, AWGS 2019 also introduces "possible sarcopenia," defined by either low muscle strength or low physical performance only, specifically for use in primary health care or community-based health promotion, to enable earlier lifestyle interventions. Although defining sarcopenia by body mass index-adjusted muscle mass instead of height-adjusted muscle mass may predict adverse outcomes better, more evidence is needed before changing current recommendations. Lifestyle interventions, especially exercise and nutritional supplementation, prevail as mainstays of treatment. Further research is needed to investigate potential long-term benefits of lifestyle interventions, nutritional supplements, or pharmacotherapy for sarcopenia in Asians.