Sarcopenic obesity research perspectives outlined by the sarcopenic obesity global leadership initiative (SOGLI) - Proceedings from the SOGLI consortium meeting in rome November 2022

Obesity and menopause

Obesity is not a choice or a result of lack of willpower, but a multifactorial, chronic, progressive, and relapsing disease. During menopause, hormonal and body composition changes lead to greater visceral adiposity, that aggravates women's health at a cardiometabolic, mechanic and mental level. Adiposity has been identified as an important modifier of reproductive hormones. During female midlife, obesity has been associated with menstrual cycle alterations (anovulatory cycles ending with abnormal bleedings), menopausal symptoms including hot flashes, poor quality of sleep, aches and joint pain, genitourinary symptoms, and reduced quality of life. However, the relationships between weight, the menopausal process, aging, and hormone levels remain poorly understood. Women with obesity have an increased risk of thromboembolic disease when using menopause hormone therapy (MHT), and it is probably the main medical condition to prescribe or not MHT. However, this risk depends on the route and type of MHT. The use of estrogen-only or combined transdermal MHT does not increase the risk of a thrombotic event in women with obesity.

Sarcopenic obesity and reduced BMD in young men living with HIV: body composition and sex steroids interplay

PURPOSE

Sex steroids play a key role on male bone homeostasis and body composition (BC), their role in men living with HIV (MLWH) is less recognized. This study aimed at investigating the prevalence of low BMD, sarcopenia, and sarcopenic obesity (SO) and their relationship with sex steroids in MLWH aged < 50.

METHODS

Prospective, cross-sectional, observational study on MLWH younger than 50 (median age 47.0 years). BC and BMD were evaluated with DXA. Two different definitions of sarcopenia were applied: appendicular lean mass/height2 (ALMI) < 7.26 kg/m2 or appendicular lean mass/body weight (ALM/W) < 28.27%. Low BMD was defined for Z-score < -2.0. Sarcopenia coupled with obesity identified SO. Serum total testosterone (T) and estradiol (E2) were measured by LC-MS/MS; free testosterone (cFT) was calculated by Vermeulen equation.

RESULTS

Sarcopenia was detected in 107 (34.9%) and 44 (14.3%) out of 307 MLWH according to ALMI and ALM/W, respectively. The prevalence of SO was similar by using both ALMI (11.4%) and ALM/W (12.4%). Sarcopenic and SO MLWH had lower total T and cFT in both the definition for sarcopenia. BMD was reduced in 43/307 (14.0%). Serum E2 < 18 pg/mL was an independent contributing factor for sarcopenia, SO, and low BMD.

CONCLUSIONS

T and E2 are important determinants of BC even in MLWH. This is among the first studies investigating the distribution of obesity phenotypes and the prevalence of SO among MLWH showing that SO is present in 11-12% of enrolled MLWH regardless of the definition used. However, deep differences emerged using two different diagnostic definitions.

Sarcopenic obesity is associated with cardiometabolic multimorbidity in Chinese middle-aged and older adults: a cross-sectional and longitudinal study

OBJECTIVES

Sarcopenic obesity (SO) has been found to increase the risk of metabolic disorders, however, its relationship with cardiometabolic multimorbidity (CMM) remains unexplored. This study aims to investigate the potential association between SO and CMM in the middle-aged and older population.

METHODS

Our study subjects were from CHARLS. SO was defined as the combination of impaired grip strength (grip strength <28 kg for men and <18 kg for women) and increased body mass index (BMI ≥25 kg/m2). CMM was defined as having two or more cardiometabolic diseases, including diabetes mellitus, stroke, and heart disease. The participants were divided into four groups according to their sarcopenia and obesity status, and logistic regression analysis was used to examine the association between SO and CMM.

RESULTS

A total of 15,252 study subjects were included in the cross-sectional study, with an average age of 60.6 years and a male proportion of 47.4%. In the cross-sectional analysis conducted in 2015, the prevalence of CMM was highest in the SO group (9.1%), followed by the obesity (3.7%) and sarcopenia (3.5%) group. After adjustment for confounding factors, SO [OR (95%CI): 2.453 (1.742-3.455)], sarcopenia [OR (95% CI): 1.601 (1.157-2.217)], obesity [OR (95% CI): 1.446 (1.107-1.888)] were all observed to be associated with CMM, with the strongest association in the SO group. Furthermore, in the longitudinal analysis, only the SO group demonstrated a significant risk for developing CMM [OR (95% CI): 2.302 (1.239-4.228)].

CONCLUSIONS

SO was independently and positively associated with CMM in middle-aged and older population.

Sarcopenic obesity in patients with head and neck cancer is predictive of critical weight loss during radiotherapy

The impact of computed tomography-defined sarcopenia on outcomes in head and neck cancer has been well described. Sarcopenic obesity (SO) (depleted muscle mass combined with obesity) may pose a more serious risk than either condition alone. We investigated SO and its impact on survival and critical weight loss (≥ 5 %) in patients with head and neck cancer who received curative radiotherapy (± other modalities). Retrospective analysis of computed tomography cross-sectional muscle at cervical (C3), thoracic (T2) and lumbar (L3) regions was conducted. Patients were grouped by BMI and sarcopenia status based on established thresholds. A total of 413 patients were included for analysis, the majority having oropharyngeal carcinoma (52 %), and 56 % received primary concurrent chemoradiotherapy. The majority of the cohort (65 %) was overweight or obese (BMI ≥ 25 kg/m2). Sarcopenia was found in 43 %, with 65 % having SO (n 116), equating to 28 % of the whole cohort. Critical weight loss was experienced by 58 % (n 238). A significantly higher proportion of patients with SO experienced critical weight loss (n 70 v. 19, P < 0·001) and were four times more likely to do so during treatment (OR 4·1; 95 % CI 1·5, 7·1; P = 0·002). SO was not found to impact on overall or cancer-specific survival; however, in patients with sarcopenia, those with SO had better overall survival (median 9·1 v. 7·0 years; 95 % CI 5·2, 16·8; P = 0·021). SO at the time of presentation in patients with head and neck cancer is predictive of critical weight loss during treatment, and muscle evaluation can be useful in identifying patients at nutritional risk regardless of BMI and obvious signs of wasting.

Influence of Body Composition Assessed by Computed Tomography on Mortality Risk in Young Women with Breast Cancer

Background/Objectives: Increasing evidence indicates that body composition can significantly influence prognosis in women with breast cancer. However, alterations in body composition, particularly among young women (<40 years), remain largely unknown and underexplored. This study aimed to investigate the relationship of computed tomography (CT)-derived body composition with mortality rates among young women recently diagnosed with breast cancer, identifying the best-correlated cutoff value. Methods: This is a bi-set cohort study with retrospective data collection. Women newly diagnosed with ductal invasive breast cancer, aged 20 to 40 years, treated in reference oncology units were included. Body composition was assessed using CT scans at the third lumbar vertebra (L3) level, including muscle and adipose compartments. The outcome of interest was the incidence of overall mortality. A maximally selected log-rank Cox-derived analysis was employed to assess the cutoffs associated with mortality. Results: A total of 192 women were included before any form of treatment (median age of 35 years, IQ range: 31-37). Overall mortality occurred in 12% of the females. Stages III-IV were the most frequent (69.5%). Patients who died had a significantly lower muscle area index. CT-derived muscle area was inversely associated with mortality. Each 1 cm2/m2 decrease in skeletal muscle index increased the mortality hazard by 9%. Higher values of adiposity compartments were independently associated with higher mortality. Conclusions: Our study highlights the predictive significance of skeletal muscle area and adipose tissue in predicting survival among young women recently diagnosed with breast cancer.

Nutritional considerations with antiobesity medications

The improved efficacy and generally favorable safety profile of recently approved and emerging antiobesity medications (AOMs), which result in an average weight reduction of ≥15%, represent significant advancement in the treatment of obesity. This narrative review aims to provide practical evidence-based recommendations for nutritional assessment, management, and monitoring of patients treated with AOMs. Prior to treatment, clinicians can identify preexisting nutritional risk factors and counsel their patients on recommended intakes of protein, dietary fiber, micronutrients, and fluids. During treatment with AOMs, ongoing monitoring can facilitate early recognition and management of gastrointestinal symptoms or inadequate nutrient or fluid intake. Attention should also be paid to other factors that can impact response to treatment and quality of life, such as physical activity and social and emotional health. In the context of treatment with AOMs, clinicians can play an active role in supporting their patients with obesity to improve their health and well-being and promote optimal nutritional and medical outcomes.

Sarcopenic Obesity and Cardiovascular Disease: An Overlooked but High-Risk Syndrome

PURPOSE OF REVIEW

Sarcopenic obesity (SO), defined as the coexistence of excess fat mass and reduced skeletal muscle mass and strength, has emerged as an important cardiovascular risk factor, particularly in older adults. This review summarizes recent findings on the diagnosis, prevalence, health impacts, and treatment of SO.

RECENT FINDINGS

Growing evidence suggests SO exacerbates cardiometabolic risk and adverse health outcomes beyond either condition alone; however, the heterogeneity in diagnostic criteria and the observational nature of most studies prohibit the evaluation of a causal relationship. This is concerning given that SO is increasing with the aging population, although that is also difficult to assess accurately given wide-ranging prevalence estimates. A recent consensus definition proposed by the European Society for Clinical Nutrition and Metabolism and the European Association for the Study of Obesity provides a framework of standardized criteria to diagnose SO. Adopting uniform diagnostic criteria for SO will enable more accurate characterization of prevalence and cardiometabolic risk moving forward. Although current management revolves around diet for weight loss coupled with resistance training to mitigate further muscle loss, emerging pharmacologic therapies have shown promising results. As the global population ages, diagnosing and managing SO will become imperative to alleviate the cardiovascular burden.

Detecting sarcopenia in obesity: emerging new approaches

PURPOSE OF REVIEW

Sarcopenic obesity is a likely common, but certainly underestimated obesity phenotype, with an important negative clinical impact. Its definition and diagnosis have however remained elusive until recently.

RECENT FINDINGS

Substantial progress has been recently made in sarcopenic obesity diagnostic tools, with the first international consensus proposed by the European Society for Clinical Nutrition and Metabolism (ESPEN) and the European Association for the Study of Obesity (EASO). Very encouraging results emerge from initial implementation of the ESPEN-EASO algorithm. In addition, even more recent progress in global consensus on sarcopenia conceptual definition is likely to further enhance consistency in sarcopenic obesity identification. The latter Global Leadership Initiative on Sarcopenia (GLIS) initiative also adopted a new definition of muscle specific strength. Its inclusion in sarcopenia diagnostic constructs opens the possibility of its potential evaluation in sarcopenic obesity, also considering the emerging positive impact of obesity treatment and fat loss on muscle functional parameters.

SUMMARY

New consensus tools for sarcopenic obesity diagnosis are likely to improve awareness, understanding, identification and treatment of this under-recognized obesity phenotype.

Nutritional Management and Physical Activity in the Treatment of Sarcopenic Obesity: A Review of the Literature

BACKGROUND

The prevalence of sarcopenic obesity among adults aged ≥65 years is increasing worldwide. It is a condition that describes the concomitant presence of sarcopenia and obesity, but it appears to be associated with greater increases in the risks for disability, morbidity, and mortality than the two conditions combined. The current review aims to summarize the available literature data on the effectiveness of lifestyle modification for the management of this high-risk geriatric syndrome.

METHODS

We conducted a comprehensive search across multiple databases, including PubMed, Scopus, Web of Science, and Cochrane Library, for publications published from January 1950 to June 2024.

RESULTS

The detection of early preventive and therapeutic approaches to combat sarcopenic obesity is essential for healthy aging. There is ample evidence that suggests that poor dietary habits and physical inactivity are the main reasons for the development of sarcopenic obesity and should thus be the main targets for intervention. In the absence of effective pharmacological interventions, the best effect on sarcopenic obesity is achieved by combination with proper dietary intervention and regular physical activity according to the individual's health condition.

CONCLUSIONS

Further research is needed to discover the most effective strategy for the prevention and treatment of sarcopenic obesity, as well as potential pharmacological options to improve muscle mass and function in older populations with physical restrictions.

Strength-to-muscle radiodensity: A potential new index for muscle quality

BACKGROUND & AIMS

Although it is widely recognized that muscle quality significantly influences adverse outcomes in patients with cancer, the precise definition of muscle quality remains elusive. The muscle quality index (MQI), also known as muscle-specific strength, is a relatively recent functional concept of muscle quality. It is obtained through the ratio of muscle strength to muscle mass, but its predictive value in patients with cancer remains unknown. In this study, we explored the prognostic significance of MQI in patients with cancer. Furthermore, we introduce and assess the prognostic potential of a novel muscle quality metric: the strength-to-muscle-radiodensity index (SMRi).

METHODS

A secondary analysis was conducted on a prospective cohort study. CT scans were opportunistically used to assess body composition parameters, including skeletal muscle mass (SM in cm2) and muscle radiodensity (SMD in HU) at the third lumbar vertebra (L3). Handgrip strength (HGS) was measured. MQICT was calculated using the ratio of HGS to SM (cm2). SMRi was calculated as the ratio of HGS to SMD (HU). For analysis purposes, low MQICT and SMRi were defined using two approaches: statistical cutoffs associated with survival, and median-based distribution data.

RESULTS

A total of 250 patients were included (52.8% females, 52% adults, 20-90 years). Gastrointestinal tumors and stage III-IV were the most frequent diagnosis and stages. SMRi and MQICT were strongly positively correlated (ρ = 0.71 P < 0.001). Individual components of MQICT and SMRi were also positively correlated. Patients with both low MQICT and SMRi had shorter survival (log-rank P = 0.023 and P = 0.003, respectively). When applying median distribution cutoffs, SMRi emerged as the most accurate predictor of mortality (HR adjusted 3.18, 95% CI 1.50 to 6.75, C-index: 0.71), when compared to MQICT (HR adjusted 1.49, 95% CI 0.77 to 2.87, C-index: 0.68).

CONCLUSION

This study introduces the concept and potential prognostic significance of the SMRi. The physiological and clinical implications of this new index warrant further investigation across a spectrum of diseases, including cancer.

Factors associated with sarcopenic obesity in Brazilian adults and older people: Systematic review and meta-analysis of observational studies

AIM

Sarcopenic obesity (SO) is characterized by the coexistence of the loss of muscle mass and function with excess adipose tissue. Its prevalence has increased concomitantly with population aging, becoming one of the most significant challenges for public health, threatening the quality of life and the physical and mental health of the elderly population.

METHODS

This study estimated the prevalence and factors associated with SO among adults and the elderly in Brazil's macro-regions, utilizing MEDLINE, Embase, Web of Science, and the Virtual Health Library databases. Primary outcomes included SO prevalence overall and by subgroups, with secondary outcomes identifying associated factors.

RESULTS

A systematic review of 33 studies with 10 266 participants up to July 2023 showed a 17% prevalence of SO (95% confidence interval: 13-21%), using a random effects meta-analysis. The Central-West region had the highest occurrence (27%). Dual-energy X-ray absorptiometry (26%) and bioimpedance (6%) were the top diagnostic methods. Protective factors were chronic kidney disease and healthy lifestyles; risk factors included socioeconomic status, functionality, lifestyle, biochemical parameters, and comorbidities such as osteoarthritis and apnea.

CONCLUSIONS

The prevalence of SO in Brazil is significant, emerging as a critical public health problem. It is essential to direct attention to changes in prevalence rates in the coming years, given the rising obesity trends and the absolute increase in the elderly population. Geriatr Gerontol Int 2024; 24: 661-674.

Analysis of sarcopenic obesity prevalence and diagnostic agreement according to the 2022 ESPEN and EASO Consensus in hospitalized older adults with severe obesity

Background

Sarcopenic obesity (SO) is a clinical disorder characterized by increased adiposity and decreased muscle mass and function, commonly observed in older adults. However, most of the studies that investigated SO prevalence rates were not based on current standardized diagnostic methods. Thus, this study aims to estimate the prevalence rates of SO and their level of agreement using different instruments proposed by the European Society for Clinical Nutrition and Metabolism (ESPEN) and the European Association for the Study of Obesity (EASO) Consensus, in a sample of hospitalized older adults with severe obesity.

Methods

A cross-sectional study with 90 older adults (≥ 60 years) with severe obesity (body mass index ≥ 35 kg/m/²) seeking an in-hospital multidisciplinary body weight reduction program. Skeletal muscle function was assessed using the five-repetition Sit-Stand test (5-SSt) and Handgrip Strength (HGS). Body composition was evaluated by high percentages of fat mass (FM), low appendicular lean mass (ALM/W), and skeletal muscle mass (SMM/W), adjusted to body weight. The stage of SO was assessed on the presence of at least one comorbidity and specific cut-offs were adopted for each step. All analyses were performed according to gender and age range.

Results

The prevalence rates of SO in the total sample were 23.3%, 25.5%, 31.1%, and 40.0% considering altered values of 5-SSt+FM+ALM/W, HGS+FM+ALM/W, 5-SSt+FMSSM/W, and HGS+FM+SSM/W, respectively. Higher prevalence rates were observed among female and old elderly subgroups, regardless of the diagnostic combination. There were weak agreements between the muscle function tests (5-SSt versus HGS) using both muscle mass indexes in the total sample and all subgroups. Moderate agreements were observed between muscle mass indexes (SMM/W versus ALM/W) in the total sample, male and younger older adults (using 5-SSt), and strong agreements for men and younger older adults (using HGS).

Conclusion

The discrepancies observed between the prevalence rates and their levels of agreement reinforce the need for new studies in similar populations aiming for better standardization of SO assessment.

Identification of factors associated with sarcopenic obesity development: Literature review and expert panel voting

Sarcopenic obesity (SO) is defined as the combination of excess fat mass (obesity) and low skeletal muscle mass and function (sarcopenia). The identification and classification of factors related to SO would favor better prevention and diagnosis. The present article aimed to (i) define a list of factors related with SO based on literature analysis, (ii) identify clinical conditions linked with SO development from literature search and (iii) evaluate their relevance and the potential research gaps by consulting an expert panel. From 4746 articles screened, 240 articles were selected for extraction of the factors associated with SO. Factors were classified according to their frequency in the literature. Clinical conditions were also recorded. Then, they were evaluated by a panel of expert for evaluation of their relevance in SO development. Experts also suggested additional factors. Thirty-nine unique factors were extracted from the papers and additional eleven factors suggested by a panel of experts in the SO field. The frequency in the literature showed insulin resistance, dyslipidemia, lack of exercise training, inflammation and hypertension as the most frequent factors associated with SO whereas experts ranked low spontaneous physical activity, protein and energy intakes, low exercise training and aging as the most important. Although literature and expert panel presented some differences, this first list of associated factors could help to identify patients at risk of SO. Further work is needed to confirm the contribution of factors associated with SO among the population overtime or in randomized controlled trials to demonstrate causality.

Clinical nutrition in primary care: ESPEN position paper

Primary care healthcare professionals (PCHPs) are pivotal in managing chronic diseases and present a unique opportunity for nutrition-related disease prevention. However, the active involvement of PCHPs in nutritional care is limited, influenced by factors like insufficient education, lack of resources, and time constraints. In this position paper The European Society for Clinical Nutrition and Metabolism (ESPEN) promotes the active engagement of PCHPs in nutritional care. We emphasize the importance of early detection of malnutrition by screening and diagnosis, particularly in all individuals presenting with risk factors such as older age, chronic disease, post-acute disease conditions and after hospitalization for any cause. ESPEN proposes a strategic roadmap to empower PCHPs in clinical nutrition, focusing on education, tools, and multidisciplinary collaboration. The aim is to integrate nutrition into medical curricula, provide simple screening tools for primary care, and establish referral pathways to address malnutrition systematically. In conclusion, we urge for collaboration with PCHP organizations to raise awareness, enhance nutrition skills, facilitate dietitian accessibility, establish multidisciplinary teams, and promote referral pathways, thereby addressing the underestimated clinical challenge of malnutrition in primary care.

Examining variations in body composition among patients with colorectal cancer according to site and disease stage

Patients with colorectal cancer (CRC) often exhibit changes in body composition (BC) which are associated with poorer clinical outcomes. Many studies group colon and rectal cancers together, irrespective of staging, potentially affecting assessment and treatment strategies. Our study aimed to compare BC in patients with CRC focusing on tumor location and metastasis presence. A total of 635 individuals were evaluated, with a mean age of 61.8 ± 12.4 years and 50.2% female. The majority had rectal cancer as the primary cancer site (51.0%), and 23.6% had metastatic disease. The first regression model showed tumor site and metastasis as independent factors influencing skeletal muscle (SM), skeletal muscle index (SMI), and visceral adipose tissue variability (all p values < 0.05). The second model, adjusted for BMI, indicated tumor site as the primary factor affecting SMI variations (adjusted R2 = 0.50 p < 0.001), with colon tumors inversely associated with SM (standardized β - 2.15(- 3.3; - 0.9) p < 0.001). A third model, considering all the confounders from the directed acyclic graphs, was constructed and the found association remained independent. Our findings highlight significant BC variations in patients with CRC, influenced by tumor location and metastases presence, underscoring the need for location-specific assessment in CRC management.

Sarcopenic obesity in older adults: a clinical overview

Sarcopenic obesity is characterized by a concurrent decline in muscle mass and function, along with increased adipose tissue. Sarcopenic obesity is a growing concern in older adults owing to significant health consequences, including implications for mortality, comorbidities and risk of developing geriatric syndromes. A 2022 consensus statement established a new definition and diagnostic criteria for sarcopenic obesity. The pathophysiology of this condition involves a complex interplay between muscle, adipose tissue, hormonal changes, inflammation, oxidative stress and lifestyle factors, among others. Sarcopenic obesity is treated with a range of management approaches, such as lifestyle interventions, exercise, nutrition and medical therapies. Emerging therapies that were developed for treating other conditions may be relevant to sarcopenic obesity, including novel pharmacological agents and personalized approaches such as precision medicine. In this Review, we synthesize the current knowledge of the clinical importance of sarcopenic obesity, its assessment and diagnosis, along with current and emerging management strategies.

Sarcopenic obesity and the impact on bone health

PURPOSE OF REVIEW

Sarcopenic obesity is a newly identified pathological entity defined by an increase in body fat mass with an associated sarcopenia, characterized by loss of muscle mass, strength, and function. Recently, the concomitant presence of skeletal alteration with sarcopenic obesity has been described leading to a new clinical entity defined osteosarcopenic obesity (OSO). Many studies have tried to unravel the metabolic complex mechanism leading to this clinical entity in order to understand the pathophysiology of this complex condition with the aim of posing an early diagnosis to improve the therapeutic approaches. The purpose of this narrative review is to highlight and revise recent studies on this issue.

RECENT FINDINGS

Recent research in the field of OSO has highlighted the role of nutrition and physical activity in the development and management of these conditions. While molecular and cellular pathways remain partially understood, there is a growing focus on lifestyle interventions as key factors in reducing the impact of OSO. These studies emphasize the need for early diagnosis and appropriate therapeutic strategies to improve quality of life and decrease morbidity and mortality associated with OSO.

SUMMARY

Although the pathophysiological pathways underlying OSO are not fully understood, the clinical implications underscore the need for expanded research in this field. This research is crucial for enabling early diagnosis and implementing effective therapeutic interventions, with the goal of reducing morbidity and mortality and enhancing quality of life.

Body composition assessment with ultrasound muscle measurement: optimization through the use of semi-automated tools in colorectal cancer

Colorectal cancer (CRC) is a disease with a high prevalence and major impact on global health. Body composition (BC) data are of great importance in the assessment of nutritional status. Ultrasound (US) is an emerging, accessible and non-invasive technique that could be an alternative when it is not feasible to perform computed tomography (CT). The aim of this study is to evaluate the correlation between CT, as a reference technique, and US of the rectus femoris (RF) as a "proof of concept," in a cohort of patients with CRC and assess the optimisation of results obtained by US when performed by our new semi-automated tool. A single-centre cross-sectional study including 174 patients diagnosed with CRC and undergoing surgery was carried out at the Vall d'Hebron Hospital. We found a strong correlation between CT and US of the RF area (r = 0.67; p < 0.005). The latter, is able to discriminate patients with worse prognosis in terms of length of hospital stay and discharge destination (AUC-ROC = 0.64, p 0.015). These results improve when they are carried out with the automatic tool (area AUC-ROC = 0.73, p 0.023), especially when normalised by height and eliminating patients who associate overflow. According to our results, the US could be considered as a valuable alternative for the quantitative assessment of muscle mass when CT is not feasible. These measurements are improved when measuring software is applied, such as "Bat" software.

Challenges in identifying malnutrition in obesity; An overview of the state of the art and directions for future research

(Protein-energy) malnutrition in individuals living with obesity presents complex diagnostic challenges due to the distinctive physiological characteristics of obesity. This narrative review critically examines the identification of malnutrition within the population with obesity, distinguishing malnutrition in obesity from related conditions such as sarcopenic obesity. While noting some shared features, the review highlights key differences between these conditions. The review also highlights the limitations of current malnutrition screening tools, which are not designed for individuals living with obesity. These tools primarily rely on anthropometric measurements, neglecting (among others) nutrient intake assessment, which hinders accurate malnutrition detection. Additionally, this review discusses limitations in existing diagnostic criteria, including the Global Leadership Initiative on Malnutrition (GLIM) criteria, when applied to individuals living with obesity. Challenges include the identification of appropriate cut-off values for phenotypic criteria (unintentional weight loss, low body mass index and muscle mass) and aetiological criteria such as reduced food intake and inflammation for the population with obesity. Overall, this review emphasises the need for modified screening tools and diagnostic criteria to recognise and assess malnutrition in obesity, leading to improved clinical outcomes and overall wellbeing.

Sarcopenia and Sarcopenic Obesity and Mortality Among Older People

Importance

Sarcopenia and obesity are 2 global concerns associated with adverse health outcomes in older people. Evidence on the population-based prevalence of the combination of sarcopenia with obesity (sarcopenic obesity [SO]) and its association with mortality are still limited.

Objective

To investigate the prevalence of sarcopenia and SO and their association with all-cause mortality.

Design, Setting, and Participants

This large-scale, population-based cohort study assessed participants from the Rotterdam Study from March 1, 2009, to June 1, 2014. Associations of sarcopenia and SO with all-cause mortality were studied using Kaplan-Meier curves, Cox proportional hazards regression, and accelerated failure time models fitted for sex, age, and body mass index (BMI). Data analysis was performed from January 1 to April 1, 2023.

Exposures

The prevalence of sarcopenia and SO, measured based on handgrip strength and body composition (BC) (dual-energy x-ray absorptiometry) as recommended by current consensus criteria, with probable sarcopenia defined as having low handgrip strength and confirmed sarcopenia and SO defined as altered BC (high fat percentage and/or low appendicular skeletal muscle index) in addition to low handgrip strength.

Main Outcome and Measure

The primary outcome was all-cause mortality, collected using linked mortality data from general practitioners and the central municipal records, until October 2022.

Results

In the total population of 5888 participants (mean [SD] age, 69.5 [9.1] years; mean [SD] BMI, 27.5 [4.3]; 3343 [56.8%] female), 653 (11.1%; 95% CI, 10.3%-11.9%) had probable sarcopenia and 127 (2.2%; 95% CI, 1.8%-2.6%) had confirmed sarcopenia. Sarcopenic obesity with 1 altered component of BC was present in 295 participants (5.0%; 95% CI, 4.4%-5.6%) and with 2 altered components in 44 participants (0.8%; 95% CI, 0.6%-1.0%). An increased risk of all-cause mortality was observed in participants with probable sarcopenia (hazard ratio [HR], 1.29; 95% CI, 1.14-1.47) and confirmed sarcopenia (HR, 1.93; 95% CI, 1.53-2.43). Participants with SO plus 1 altered component of BC (HR, 1.94; 95% CI, 1.60-2.33]) or 2 altered components of BC (HR, 2.84; 95% CI, 1.97-4.11) had a higher risk of mortality than those without SO. Similar results for SO were obtained for participants with a BMI of 27 or greater.

Conclusions and Relevance

In this study, sarcopenia and SO were found to be prevalent phenotypes in older people and were associated with all-cause mortality. Additional alterations of BC amplified this risk independently of age, sex, and BMI. The use of low muscle strength as a first step of both diagnoses may allow for early identification of individuals at risk for premature mortality.

Specific bioelectrical vectors pattern in individuals with sarcopenic obesity

BACKGROUND

Sarcopenic obesity is a common condition in the elderly associated with excessive adiposity and low muscle mass and strength.

AIMS

This study aims to establish a method for detecting bioelectrical characteristics in individuals with sarcopenic obesity through specific Bioelectrical Impedance Vector Analysis (specific BIVA), while considering the characteristics of individuals with healthy, sarcopenic, and obese conditions.

METHODS

The sample was composed by 915 Italian adults over 50 years of age (men: 74.6 ± 8.8 y; women:76.3 ± 8.8 y) living in Sardinia (Italy). A dataset of 1590 US adults aged 21 - 49 years retrieved from the 2003 - 2004 National Health and Nutrition Examination Survey was also considered in a final step of the study. Anthropometric (stature, weight, waist, arm, and calf circumferences) and whole-body bioelectrical variables were taken. In the Italian sample, bioelectrical impedance was applied to estimate the relative content of fat mass and skeletal muscle mass. Groups with healthy body composition (NS-NO), or consistent with sarcopenia (S), sarcopenic obesity (S-O), and obesity (O) were defined based on the cut-offs suggested by European expert guidelines (EWGSOP2 and ESPEN-EASO). Specific BIVA was applied to compare groups and to identify the area for sarcopenic obesity within young-adults tolerance ellipses. The position of the specific vector of US individuals with S-O, selected on the basis of DXA measurements, was also considered.

RESULTS

In both sexes of the Italian sample, the bioelectrical characteristics of the four groups were different (p < 0.001). The differences were mainly related to vector length, indicative of higher fat mass, which was longer in the O and S-O groups, and phase angle, a proxy of intracellular/extracellular water and muscle mass, lower in the sarcopenic groups. Bioelectrical vectors of the S-O group fell in the right quadrant, outside of the 95 % tolerance ellipses of young adults. The mean vector of the US sample with S-O fell in the same area. Within the S-O area, women had similar bioelectrical values, while men showed phase angle variability, which was related to the severity of the condition.

CONCLUSIONS

Specific BIVA detects body composition peculiarities of individuals with sarcopenic obesity, thus allowing their diagnosis when associated with low handgrip strength values.

Editorial: nutrition at key stages of the lifecycle

Nutritional requirements of individuals vary across the lifecycle, according to activity, age and gender. To optimize human health, consideration of nutritional priorities at each stage is needed. This conference brought together multidisciplinary experts in maternal and child nutrition and health, cardiometabolic and plant-based nutrition and dietitians involved in the care of vulnerable populations, plus nutritional metabolism, health and ageing. The presentations highlighted the most important nutrition research in these areas, updating knowledge and suggesting how dietary advice and policy could be adapted to incorporate research findings. With the global increase in non-communicable disease (NCD) and nutrition being considered as a key modifiable risk factor for the prevention and management of NCD, this conference was much needed.

Impact of EASO/ESPEN-Defined Sarcopenic Obesity Following a Technology-Based Weight Loss Intervention

BACKGROUND

Sarcopenic Obesity is the co-existence of increased adipose tissue (obesity) and decreased muscle mass or strength (sarcopenia) and is associated with worse outcomes than obesity alone. The new EASO/ESPEN consensus provides a framework to standardize its definition. This study sought to evaluate whether there are preliminary differences observed in weight loss or physical function in older adults with and without sarcopenic obesity taking part in a multicomponent weight loss intervention using these new definitions.

METHODS

A 6-month, non-randomized, non-blinded, single-arm pilot study was conducted from 2018 to 2020 in adults ≥ 65 years with a body mass index (BMI) ≥ 30 kg/m2. Weekly dietitian visits and twice-weekly physical therapist-led exercise classes were delivered using telemedicine. We conducted a secondary retrospective analysis of the parent study (n = 53 enrolled, n = 44 completers) that investigated the feasibility of a technology-based weight management intervention in rural older adults with obesity. Herein, we applied five definitions of sarcopenic obesity (outlined in the consensus) to ascertain whether the response to the intervention differed among those with and without sarcopenic obesity. Primary outcomes evaluated included weight loss and physical function (30-s sit-to-stand).

RESULTS

In the parent study, mean weight loss was - 4.6 kg (95% CI - 3.6, - 5.6; p < 0.001). Physical function measures of 30-s sit-to-stand showed a mean increase of 3.1 in sit-to-stand repetitions (+ 1.9, + 4.3; p < 0.001). In this current analysis, there was a significant decrease in weight and an increase in repetitions between baseline and follow-up within each group of individuals with and without sarcopenia for each of the proposed definitions. However, we did not observe any significant differences in the changes between groups from baseline to follow-up.

CONCLUSIONS

The potential lack of significant differences in weight loss or physical function between older adults with and without sarcopenic obesity participating in a weight loss intervention may suggest that well-designed, multicomponent interventions can lead to similar outcomes irrespective of sarcopenia status in persons with obesity. Fully powered randomized clinical trials are critically needed to confirm these preliminary results.

Indices of sarcopenic obesity are important predictors of finite element analysis-derived bone strength in older adults with obesity

Background

The expanding population of older adults with obesity is a public health challenge, in part, because of the increased risk of fractures despite normal or high bone mineral density. Potential factors predisposing to fractures in this group include sarcopenia associated with obesity and impaired bone quality. We aimed to determine the contribution of sarcopenic obesity (SO) indices to bone strength as assessed by microfinite element analysis (μFEA) of high-resolution peripheral quantitative computed tomography (HR-pQCT).

Methods

One-hundred eighty-nine older (age ≥ 65 years) adults with obesity (BMI ≥ 30 kg/m2) participated in lifestyle intervention trials at our medical center. All underwent baseline measurements of bone strength (failure load and stiffness) using μFEA from HR-pQCT of the distal radius and tibia. In addition, SO indices [appendicular lean mass/weight (ALM/W) and percent body fat (FM%)] by dual-energy X-ray absorptiometry and handgrip strength (HGS) by dynamometry were assessed. SO was diagnosed and staged based on the 2022 ESPEN and EASO expert consensus statement.

Results

Both ALM/W and HGS were positively correlated explaining 28% to 36% of the variance in failure load and stiffness at the distal radius and tibia (all p < 0.001). In contrast, FM% was negatively correlated explaining 22% to 31% of the variance in failure load and stiffness at the distal radius and tibia (all p < 0.001). The associations of SO indices with failure load and stiffness remained significant after controlling for age, sex, race/ethnicity, diabetes, and 25-OH vitamin D (ALM/W: R 2 = 0.301 to 0.448, HGS: R 2 = 0.346 to 0.472, FM%: R 2 = 0.299 to 0.432) (p < 0.001 to 0.011). SO was diagnosed in 75/189 (40%) participants with 66/75 (88%) having functional or metabolic complications (stage II). Participants with SO had lower failure load and stiffness at the distal radius than participants with no SO (both p < 0.05).

Conclusion

These findings demonstrate that lower muscle mass and strength and higher fat mass may impair bone quality. Therefore, interventions that focus on preserving muscle mass and strength while reducing fat mass may be important to decrease fracture risk when older adults with obesity undertake lifestyle intervention therapy.

Chronic intermittent hypoxia due to obstructive sleep apnea slightly alters nutritional status: a pre-clinical study

Obstructive sleep apnea syndrome (OSAS) is associated with chronic intermittent hypoxia (cIH) that causes disturbances in glucose and lipid metabolism. Animals exposed to cIH show lower body weight and food intake, but the protein-energy metabolism has never been investigated. Here, to address the gap, we studied the impact of cIH on nutritional status in rats. A total of 24 male Wistar rats were randomized into 3 groups (n = 8): a control group (Ctrl), a cIH group (cIH) exposed to cIH (30 s 21-30 s 5% fraction of inspired oxygen, 8 h per day, for 14 days), and a pair-fed group (PF) exposed to normoxia with food intake adjusted to the intake of the cIH group rats with anorexia. Body weight and food intake were measured throughout the study. After 14 days, the rats were euthanized, the organs were collected, weighed, and the liver, intestine mucosa, and muscles were snap-frozen to measure total protein content. Food intake was decreased in the cIH group. Body weight was significantly lower in the cIH group only (-11%, p < 0.05). Thymus and liver weight as well as EDL protein content tended to be lower in the cIH group than in the Ctrl and PF groups. Jejunum and ileum mucosa protein contents were lower in the cIH group compared to the PF group. cIH causes a slight impairment of nutritional status and immunity. This pre-clinical work argues for greater consideration of malnutrition in care for OSAS patients. Further studies are warranted to devise an adequate nutritional strategy.

Discovering the Individualized Factors Associated with Sarcopenia and Sarcopenic Obesity Phenotypes-A Machine Learning Approach

The literature shows how sarcopenia often occurs along with different phenotypes based either on the concomitant presence of adipose tissue excess (i.e., sarcopenic obesity, SO), or osteopenia/osteoporosis (osteosarcopenia, OS), or the combination of the two conditions, so-called osteosarcopenic obesity (OSO). This research aimed to assess the prevalence of sarcopenia phenotypes (SO, OS, OSO), their associated risk factors and their health impact in a population of out- and inpatients living in the North of Italy. Male and female subjects aged ≥18 years were enrolled for the study. A blood sample was collected to measure targeted blood makers. A comprehensive anthropometric clinical assessment (height, weight, Body Mass Index, BMI and Dual Energy X-ray Absorptiometry, DXA) was performed to measure ponderal, bone, fat, and muscle status. A total of 1510 individuals participated to the study (females, n = 1100; 72.85%). Sarcopenia was the most prevalent phenotype (17%), followed by osteosarcopenia (14.7%) and sarcopenic obesity. Only 1.9% of the sample was affected by OSO. According to logistic regression analysis, sarcopenia was associated with age, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) (positively) and BMI, Iron (Fe), Total Cholesterol, albumin (%), albumin (g), and gamma proteins (negatively). Sarcopenic obesity was associated with age, ferritin, ESR, CRP (positively) and BMI, Fe, and albumin (%) (negatively). Osteosarcopenia was associated with age, ESR (positively) and BMI, Total Cholesterol, albumin (%), albumin (g), and Ca (negatively). Osteosarcopenic obesity was associated with glycemia and gamma-glutamyl transferase (gGT) (positively). According to random forest analysis, a higher BMI was the most important protective factor for sarcopenia, for sarcopenic obesity (along with Iron) and for osteosarcopenia (along with albumin). Moreover, osteosarcopenic obesity was positively associated with GgT and glycaemia. The possibility of gaining such information, especially in the younger population, could help to prevent the onset of such diseases and best fit the patient's needs, according to a precision-medicine approach.

Phase angle is associated with sarcopenic obesity in post-stroke patients

BACKGROUND & AIMS

Evidence is limited concerning the association between bioimpedance analysis-derived phase angle and sarcopenic obesity. This study examined this association in patients who underwent convalescent rehabilitation after stroke.

METHODS

This cross-sectional study included hospitalized patients with post-acute stroke. The phase angle was measured using a multifrequency bioimpedance analysis. Sarcopenic obesity was diagnosed according to the European Society of Clinical Nutrition and Metabolism/European Association for the Study of Obesity criteria. A multiple linear regression analysis was used to examine the association between the phase angle and sarcopenic obesity after adjusting for confounding factors. A receiver operating characteristic curve was used to calculate the optimal phase angle cutoff value for predicting sarcopenic obesity.

RESULTS

A total of 760 patients (median age 71 years; 352 women) were analyzed. The median (interquartile range, 25th and 75th percentiles) phase angle was 4.45° (4.10°, 4.88°). Sarcopenic obesity was diagnosed in 16 (3.9%) men, 18 (5.1%) women, and 34 (4.5%) patients overall. The multiple linear regression analysis showed that sarcopenic obesity (β = -0.185, p = 0.017) and sarcopenia (β = -0.121, p = 0.012) were significantly and negatively associated with the phase angle. Obesity was not significantly associated with the phase angle (β = -0.078, p = 0.094). The optimal cutoff value of the phase angle for diagnosing sarcopenic obesity was 4.29° (sensitivity 0.65, specificity 0.80, area under the curve [AUC] 0.79, 95% CI 0.77-0.87, p < 0.001) in men and 3.84° (sensitivity 0.67, specificity 0.84, AUC 0.81, 95% CI 0.79-0.86, p < 0.001) in women.

CONCLUSION

The phase angle was associated with sarcopenic obesity, and the cutoff values of the phase angle that could predict sarcopenic obesity were 4.29° for men and 3.84° for women. This simple and practical phase angle-based prediction of sarcopenic obesity can be useful in clinical practice.

Sarcopenic obesity: emerging mechanisms and therapeutic potential

Sarcopenic obesity, or the loss of muscle mass and function associated with excess adiposity, is a largely untreatable medical condition associated with diminished quality of life and increased risk of mortality. To date, it remains somewhat paradoxical and mechanistically undefined as to why a subset of adults with obesity develop muscular decline, an anabolic stimulus generally associated with retention of lean mass. Here, we review evidence surrounding the definition, etiology, and treatment of sarcopenic obesity with an emphasis on emerging regulatory nodes with therapeutic potential. We review the available clinical evidence largely focused on diet, lifestyle, and behavioral interventions to improve quality of life in patients with sarcopenic obesity. Based upon available evidence, relieving consequences of energy burden, such as oxidative stress, myosteatosis, and/or mitochondrial dysfunction, is a promising area for therapeutic development in the treatment and management of sarcopenic obesity.

Relationship between monounsaturated fatty acids and sarcopenia: a systematic review and meta-analysis of observational studies

Accumulating evidence suggests that fatty acids (FAs) play an essential role in regulating skeletal muscle mass and function throughout life. This systematic review and meta-analysis aimed to examine the relationship between dietary or circulatory levels of monounsaturated FAs (MUFAs) and sarcopenia in observational studies. A comprehensive literature search was performed in three databases (PubMed, Scopus, and Web of Science) from inception until August 2022. Of 414 records, a total of 12 observational studies were identified for this review. Ten studies were meta-analysed, comprising a total of 3704 participants. The results revealed that MUFA intake is inversely associated with sarcopenia (standardized mean difference = - 0.28, 95% CI - 0.46 to - 0.11; p < 0.01). Despite the limited number of studies, our results suggest that lower MUFA intake is associated with a higher risk of sarcopenia. However, the available evidence is still insufficient and further investigations are needed to demonstrate this relationship.

Comparison of computed tomography and dual-energy X-ray absorptiometry in the evaluation of body composition in patients with obesity

Objective

a) To evaluate the accuracy of the pre-existing equations (based on cm2 provided by CT images), to estimate in kilograms (Kg) the body composition (BC) in patients with obesity (PwO), by comparison with Dual-energy X-ray absorptiometry (DXA). b) To evaluate the accuracy of a new approach (based on both cm2 and Hounsfield Unit parameters provided by CT images), using an automatic software and artificial intelligence to estimate the BC in PwO, by comparison with DXA.

Methods

Single-centre cross-sectional study including consecutive PwO, matched by gender with subjects with normal BMI. All the subjects underwent BC assessment by Dual-energy X-ray absorptiometry (DXA) and skeletal-CT at L3 vertebrae. CT images were processed using FocusedON-BC software. Three different models were tested. Model 1 and 2, based on the already existing equations, estimate the BC in Kg based on the tissue area (cm2) in the CT images. Model 3, developed in this study, includes as additional variables, the tissue percentage and its average Hounsfield unit.

Results

70 subjects (46 PwO and 24 with normal BMI) were recruited. Significant correlations for BC were obtained between the three models and DXA. Model 3 showed the strongest correlation with DXA (r= 0.926, CI95% [0.835-0.968], p<0.001) as well as the best agreement based on Bland - Altman plots.

Conclusion

This is the first study showing that the BC assessment based on skeletal CT images analyzed by automatic software coupled with artificial intelligence, is accurate in PwO, by comparison with DXA. Furthermore, we propose a new equation that estimates both the tissue quantity and quality, that showed higher accuracy compared with those currently used, both in PwO and subjects with normal BMI.

Sarcopenic Obesity Is a Risk Factor for Worse Oncological Long-Term Outcome in Locally Advanced Rectal Cancer Patients: A Retrospective Single-Center Cohort Study

BACKGROUND

Malnutrition and skeletal muscle waste (sarcopenia) are known as predictive factors for a poor postoperative outcome. Paradoxically, obesity seems to be associated with a survival advantage in wasting diseases such as cancer. Thus, the interpretation of body composition indices and their impact on rectal cancer therapy has become more and more complex. The aim of this study was to evaluate body composition indices in locally advanced rectal cancer patients prior to therapy and their impact on short- and long-term outcomes.

METHODS

Between 2008 and 2018, 96 patients were included in this study. Pre-therapeutic CT scans were used to evaluate visceral and subcutaneous fat mass, as well as muscle mass. Body composition indices were compared to body mass index, morbidity, anastomotic leakage rate, local recurrency rate, and oncological long-term outcomes.

RESULTS

Increased visceral fat (p < 0.01), subcutaneous fat (p < 0.01), and total fat mass (p = 0.001) were associated with overweight. Skeletal muscle waste (sarcopenia) (p = 0.045), age (p = 0.004), comorbidities (p < 0.01), and sarcopenic obesity (p = 0.02) were significantly associated with increased overall morbidity. The anastomotic leakage rate was significantly influenced when comorbidities were present (p = 0.006). Patients with sarcopenic obesity showed significantly worse disease-free (p = 0.04) and overall survival (p = 0.0019). The local recurrency rate was not influenced by body composition indices.

CONCLUSION

Muscle waste, older age, and comorbidities were demonstrated as strong risk factors for increased overall morbidity. Sarcopenic obesity was associated with worse DFS and OS. This study underlines the role of nutrition and appropriate physical activity prior to therapy.

Sarcopenic obesity in free-living older adults detected by the ESPEN-EASO consensus diagnostic algorithm: Validation in an Italian cohort and predictive value of insulin resistance and altered plasma ghrelin profile

Aging and obesity are synergistic sarcopenia risk factors (RF). Their association in sarcopenic obesity (SO) enhances morbidity and mortality, but consensus on SO diagnostic criteria is limited. ESPEN and EASO issued a consensus algorithm for SO screening (obesity and clinical SO suspicion) and diagnosis [low muscle strength by hand-grip (HGS) and low muscle mass by BIA], and we investigated its implementation in older adults (>65-years), as well as SO-associated metabolic RF [insulin resistance (IR: HOMA) and plasma acylated (AG) and unacylated (UnAG) ghrelin, with predictive value also assessed from 5-year-prior observations]. Older adults with obesity from the Italian MoMa study on metabolic syndrome in primary care (n = 76) were studied. 7 of 61 individuals with positive screening had SO (SO+; 9 % of cohort). No individuals with negative screening had SO. SO+ had higher IR, AG and plasma AG/UnAG ratio (p < 0.05 vs negative screening and SO-), and both IR and ghrelin profile predicted 5-year SO risk independent of age, sex and BMI. The current results provide the first ESPEN-EASO algorithm-based investigation of SO in free-living older adults, with 9 % prevalence in those with obesity and 100 % algorithm sensitivity, and they support IR and plasma ghrelin profile as SO risk factors in this setting.