The Diagnosis and Treatment of Sarcopenia and Sarcopenic Obesity

Abstract

Background

Sarcopenia is a progressive, generalized disease of skeletal muscle characterized by a loss of muscle strength and muscle mass. The combination of obesity and sarcopenia is called sarcopenic obesity. Because of the aging of the population in many countries around the world, sarcopenia and sarcopenic obesity are a challenge for global health policy.

Methods

This review is based on pertinent publications retrieved by a selective literature search.

Results

The effects of sarcopenia on health and quality of life are far-reaching and include difficulty coping with everyday life, an increased risk of falling, frequent hospitalization, and increased mortality. A population-based study in Germany revealed a 7% prevalence of sarcopenia in adults aged 65 and above. The prevalence of sarcopenic obesity was 4.5%. Persons aged 65 and above who are at increased risk for sarcopenia should be screened, e.g., with the SARC-F questionnaire. If screening yields a suggestive finding (SARC-F ≥ 4 points), the diagnosis of sarcopenia should be confirmed or ruled out by measurements of muscle strength (e.g. hand-grip strength, reference values: women <16 kg, men <27 kg) and appendicular muscle mass (women <5.5 kg/m², men <7.0 kg/m²). The demonstration of reduced muscle strength is sufficient to initiate treatment. For the diagnosis of sarcopenic obesity, increased fat mass is additionally required. The goal of treatment is to improve mobility and reduce negative health outcomes. The treatment consists of resistance training and nutritional interventions.

Conclusion

A targeted and structured approach to the detection and treatment of sarcopenia and sarcopenic obesity can make a major contribution to the maintenance or improvement of these patients’ functionality and quality of life.

Information on this CME

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Sarcopenia is the pathological loss of muscle strength and muscle mass (1). Its effects are far-reaching and associated with difficulty coping with everyday life, an increased risk of falling as well as a loss of independence and quality of life (2). The rates of hospitalization (hazard ratio [HR] 11.80, 95% confidence interval: [4.86; 28.65]) and mortality (HR 2.00; [1.71; 2.34]) are also increased (2–4).

The combination of obesity and sarcopenia is referred to as sarcopenic obesity (SO) (5). The prevalence of sarcopenia and SO increases with age (1, 5, 6). Chronic diseases, chronic inflammation, and certain lifestyle factors contribute to the development of sarcopenia (1, 7, 8). Reduced muscle strength and mass are key to the diagnosis, and in the case of SO, increased fat mass is additionally required (5, 8). The diagnostic work-up of sarcopenia and SO is essentially the same, but with different cut-off values applying to SO. The early detection and treatment of sarcopenia can help to reduce negative health outcomes.

Sarcopenia is defined by the loss of muscle strength and mass. The term frailty, on the other hand, describes a complex geriatric syndrome that affects the heightened vulnerability of older adults to stressors (9). Frailty involves not only the muscles but also other organ systems as well as psychological and social factors (10).

The aim of this review article is to provide a compact overview of the diagnostic and therapeutic options in the clinical setting.

Methods

A selective literature search in PubMed for publications in the period from 01/2000 to 04/2024 retrieved meta-analyses and systematic reviews on the subject of sarcopenia. Screening and diagnosis were based on the recommendations of the revised European consensus paper of the European Working Group on Sarcopenia in Older People 2 (EWGSOP2) (8) and the consensus statement of the European Society for Clinical Nutrition and Metabolism (ESPEN), as well as the European Association for the Study of Obesity (EASO) (5). The treatment recommendations are taken primarily from umbrella reviews and international guidelines (11–13). Other review articles and studies relevant to clinical work were also included.

Etiology of sarcopenia

The etiology of sarcopenia is multifactorial. Primary sacropenia refers to the age-related loss of muscle strength and mass (8). It is distinct from secondary sarcopenia, which is caused by other factors such as systemic inflammation, physical inactivity, and malnutrition (2, 8, 14). Associated factors of sarcopenia in community-dwelling older individuals are shown in eTable 1 (7). The definition of sarcopenia should not vary depending on age or diseases (such as heart failure, kidney disease, cancer, etc.) (1). Insulin resistance, dyslipidemia, lack of physical activity, inflammation, and hypertension are the most frequent risk factors for SO (15).

eTable 1. Sociodemographic and behavioral risk factors associated with sarcopenia in community-dwelling older individuals (7).

Risk factors	Association
Age (in years)*	OR = 1.12; 95% CI [1.10; 1.13]
Difficulties in activities of daily living	OR = 1.49; 95% CI [1.15; 1.92]
Smoking	OR = 1.20; 95% CI [1.10; 1.21]
Physical inactivity	OR = 1.73; 95% CI [1.48; 2.01]
Malnutrition/malnutrition risk	OR = 2.99; 95% CI [2.40; 3.72]
Underweight	OR = 3.78; 95% CI [2.55; 5.60]
Long sleeping time (> 8 h)	OR = 2.30; 95% CI [1.37; 3.86]
Short sleeping time (< 6 h)	OR = 3.32; 95% CI [1.86; 5.93]
Living alone	OR = 1.55; 95% CI [1.00; 2.40]
No partner (single, divorced, or widowed)	OR = 1.57; 95% CI [1.08; 2.28]

*The individuals investigated were 60 years or older. CI, confidence interval; OR, odds ratio

Prevalence

The German population-based study, KORA-Age, showed a 7% prevalence of sarcopenia in adults aged 65 and above (females: 8.8%, males: 5.2%). The prevalence of SO was 4.5% (females: 4.0 %, males: 5.0%) (16).

Depending on the definition and methodology used in the studies, the global prevalence of sarcopenia is between 10 and 27% in over-60-year-olds (17). Among residents in nursing homes and patients receiving inpatient care, the prevalences in men and women are 51% and 31%, respectively, and 23% and 24%, respectively (17). The global prevalence of sarcopenic obesity in adults aged over 60 years is 11% (95% CI: [10; 13]) and 23% in over-75-year-olds (6).

Diagnosis

Screening

Screening is recommended if relevant symptoms or comorbidities are reported. These include, for example:

• Difficulty performing everyday activities

• Unintentional weight loss

• Low mood

• Malnutrition

• Cognitive impairment

• Repeated falls.

Screening is particularly important in nursing homes, hospitals, and rehabilitation facilities (11, 12, 18). The SARC-F questionnaire (SARC-F: Strength, Assistance in walking, Rise from a chair, Climb stairs and Falls) is a validated screening instrument that those affected can fill out themselves (Table 1) (19). According to the EWGSOP2 definition of sarcopenia, the SARC-F has a moderate sensitivity of 53.3% (95% CI: [18.9; 87.8]) and a moderate specificity of 68.9% [54.4; 83.4]) (20). If screening yields a suggestive finding or there is clinical suspicion of sarcopenia, further diagnostic investigations should be carried out (8, 11).

Table 1. SARC-F questionnaire (19).

Component	Question	Scoring
Strength	How much difficulty do you have in lifting and carrying 10 pounds?	None = 0
		Some = 1
		A lot or unable = 2
Assistance in walking	How much difficulty do you have walking across a room?	None = 0
		Some = 1
		A lot, use aids, or unable = 2
Rise from a chair	How much difficulty do you have transferring from a chair or bed?	None = 0
		Some = 1
		A lot or unable without help = 2
Climb stairs	How much difficulty do you have climbing a flight of 10 stairs?	None = 0
		Some = 1
		A lot or unable = 2
Falls	How many times have you fallen in the past year?	None = 0
		1–3 Falls = 1
		4 or more falls = 2
		Total:
Interpretation: ≥ 4 positive screening for sarcopenia;                 < 4 no indication of sarcopenia

SARC-F, Strength, Assistance in walking, Rise from a chair, Climb stairs and Falls

*10 pounds = ca. 5 kg = Half a crate of water with one hand or a whole crate of water with two hands

Diagnostic work-up

The diagnostic work-up is based on EWGSOP2 recommendations (Table 2, eFigure) (8). In a first step, muscle strength is assessed by means of handgrip strength (HGS) or the chair stand test (CST). The CST measures the time needed to rise five times from a sitting position without using the arms. Suspicion of sarcopenia, or what is known as reduced muscle strength, is present if the maximum handgrip strength, as measured with a dynamometer, is < 16 kg in females and < 27 kg in men, or when > 15 s are required to perform the CST (8). The structured diagnostic approach is explained in the eBox using an example case in a geriatric day hospital.

Table 2. Sarcopenia diagnosis: cut-off values according to EWGSOP2 (8).

	Cut-off for women	Cut-off for men
Abnormal screening
SARC-F	≥ 4 Points
Low muscle strength
HGS	< 16 kg	< 27 kg
CST	> 15 Seconds
Low muscle mass
ASM	< 15 kg	< 20 kg
ASM/height2	< 5.5 kg/m2	< 7 kg/m2
Severe sarcopenia
SPPB	≤ 8 Points
TUG	≥ 20 Seconds
GS	≤ 0.8 m/s
400-MWT	≥ 6 Minutes or not possible

ASM, appendicular skeletal muscle mass; SARC-F, Strength, Assistance in walking, Rise from a chair, Climb stairs and Falls; CST, chair stand test; EWGSOP2, European Working Group on Sarcopenia in Older People 2; HGS, handgrip stength; SPPB, short physicalperformance battery; TUG, Timed Up and Go test; GS, gait speed; 400-MWT, 400-meter walking test

eFigure.

Diagnostic algorithm for sarcopenia according to EWGSOP2 (8)

BIA, bioelectric impedance analysis; CST, chair stand test; CT, computed tomography; DXA, dual-energy X-ray absorptiometry; GS, gait speed; HGS, handgrip strength; MRI, magnetic resonance imaging; SARC-F, Strength, Assistance in walking, Rise from a chair, Climb stairs and Falls; SPPB, short physical performance battery; TUG, Timed Up and Go test; 400-MWT, 400-m walk test

eBox. Diagnostic work-up: an example.

Screening for malnutrition (MNA-SF) and sarcopenia (SARC-F) is an integral part of the basic geriatric assessment upon admission to an acute geriatric day hospital. These screening instruments are used in the initial medical examination (< 24 h). Screening examinations can be supplemented, for example, by functional tests such as handgrip strength, gait speed, chair stand test, Timed Up and Go test etc., which are key components of the admission process. The aim of the assessment carried out by physiotherapists is to evaluate the patient’s current status and identify any interventional options. Patients assessed to be at risk (MNA-SF ≤ 11 points and SARC-F ≥ 4 points) undergo a further nutritional therapy assessment. Irrespective of this, patients at risk for malnutrition should immediately receive treatment according to the local intervention algorithm. Geriatric patients often have not only medical diagnoses but also nutritional diagnoses, which are diagnosed by qualified nutritionists according to the G-NCP (German Nutrition Care Process). They expand on the medical diagnoses and take into consideration, for example, malnutrition as well as relevant influencing factors and resources. To optimize transsectoral communication, a comprehensive discharge report compiled by all disciplines involved (assessments, interventions, recommendations) should be provided to the medical professionals or institutions providing further care in order to enhance treatment sustainability.

If sarcopenia is suspected, appendicular skeletal muscle mass (ASM) is measured by means of bioelectrical impedance analysis (BIA) or dual-energy X-ray absorptiometry (DXA). The diagnosis of sarcopenia is considered to be confirmed in the case of low ASM values (females < 15 kg, males < 20 kg) or a low ASM:height ratio (females < 5.5 kg/m², males < 7.0 kg/m²). Due to the poor availability of instrument-based measuring methods, the options for the determination of muscle mass are limited. The demonstration of reduced muscle strength is sufficient to initiate treatment. Finally, one determines the severity of sarcopenia. There are functional tests for this, such as:

• Test to assess gait speed (GS)

• Short physical performance battery (SPPB)

• Timed Up and Go test (TUG)

• 400-m Walk test (400-MWT).

A detailed description of these tests can be found in the eSupplement.

eSupplement.

Resistance training (RT) in sarcopenia

The recommendations include:

• 2–3 Training sessions per week.

• Training the large muscle groups using a total-body approach. Proposed exercises can include squats, leg presses, knee extensions, chest presses, and seated rowing.

• Progressive exercise intensity with 40–60% of the maximum strength possible for a single repetition of an exercise (up to a maximum of 70–85%).

• It is recommended that each set be performed between one and three times, with six to 12 repetitions per set. A higher number of sets and repetitions as well as greater intensity are associated with a significant increase in muscle strength and muscle mass (34, e16, e17).

• Sufficient breaks of at least 48 h between training sessions

• Sufficient breaks of 6–120 s between sets and 3–5 min between the different exercises (12, 34).

Functional tests to grade severity

Short physical performance battery (SPPB)

The SPPB comprises three subtests. The maximum score for each subtest is 0–4 points. At the end, all points are added up. The maximum score is 12 points. This test is used to assess lower extremity function. Lower scores are associated with a higher health risk. The first subtest assesses balance. In the second subtest, the subject walks a distance of 4 m. The third subtest, the chair stand test, measures the time the subject needs to stand up from a chair and sit down again five times, without the use of the arms (e18).

Timed Up and Go (TUG)

The Timed Up and Go test can also be used to assess a person’s everyday mobility. They are asked to stand up from a seated position, walk 3 m in a straight line, return to the chair, and sit down again. The use of aids is permitted. If the test is completed within 10 s, the patient’s functional mobility is unimpaired (e19).

400-Meter walk test (400-MWT)

The subject is asked to walk 400 m at their usual pace. The time needed for this is measured (e20).

Gait speed (GS)

The subject is asked to walk a distance of 4 m on a level surface at their normal pace. Their average gait speed is calculated from the result in m/s (e21). A speed of under 1 m/s is associated with frailty, fall risk, impaired mobility, and reduced quality of life.

EWGSOP2 cut-off values for low physical performance and severe sarcopenia are: GS of ≤ 0.8 m/s, ≤ 8 points in the SPPB, ≥ 20 s in the TUG, and ≥ 6 min in the 400-MWT (8).

Diagnosis of sarcopenic obesity

Screening

The recommendations on screening and diagnosis are contained in the ESPEN and EASO consensus statement (eTable 2) (5). Screening for SO requires not only indicators of overweight (elevated body mass index [BMI] ≥ 30 kg/m² or waist circumference of ≥ 80 cm in females and ≥ 90 cm in men) but also indicators of sarcopenia (SARC-F, clinical symptoms, or clinical suspicion). Screening is positive if both indicators are outside normal ranges.

eTable 2. SO diagnostic cut-offs according to the ESPEN and EASO consensus statement (5).

	Cut-off for women	Cut-off for men
Abnormal screening
SARC-F	≥ 4 Points
BMI	≥ 30 kg/m2 for CP and ≥ 27.5 kg/m2 for AP
Waist circumference	≥ 80 cm for CP, ≥ 72 cm AP	≥ 90 cm for CP, ≥ 78 cm AP
Low muscle strength
Handgrip strength (HGS)	< 16 kg for CP < 18 kg for AP	< 27 kg for CP < 28 kg for AP
Chair stand test (CST)	> 17 Seconds
Relative low muscle mass
ALM/body weight *1	< 19.4%	< 25.7%
SMM/body weight *1	≤ 27.6%	≤ 37%
Relative increase in fat mass
FM/body weight *1 *2	> 43% for CP > 41% for AP	> 31% for CP > 29% for AP

ALM, appendicular lean mass; AP, Asian population; BMI, body mass index;

BIA, bioelectric impedance analysis; CST, chair stand test; DXA, dual-energy X-ray absorptiometry;

ESPEN, European Society for Clinical Nutrition and Metabolism; EASO, European Association forthe Study of Obesity; FM, fat mass; HGS, handgrip strength; CP, Caucasian population;

SARC-F, Strength, Assistance with walking, Rise from a chair, Climb stairs and Falls;

SMM, skeletal muscle mass; cut-off values for other groups are available in the abovementioned consensus statement (5).

*¹ ALM and FM are measured using DXA or BIA, while ALM is measured using DXA. Computed tomography can also be used to analyze body composition.

*² Validated for ages between 60 and 79 years. Alternative values for populations aged over 79 years are > 40.9% for women and > 30.33% for men.

Diagnostic work-up

Suggestive screening findings should prompt a two-stage diagnostic work-up. This includes an investigation of altered skeletal muscle strength and altered body composition (5):

• Measuring reduced skeletal muscle strength: Several tests, such as HGS or the CST, can be used to assess muscle strength. The proposed cut-offs are < 27 kg for men and < 16 kg for women in terms of HGS as well as ≥ 17 s in the CST.

• Measuring altered body composition: Body composition is generally measured using BIA or DXA (5).

  • Relative increase in fat mass: The reference values for percentage of fat mass (FM) relative to total body weight are > 43% for women and > 31% for men.

  • Relative reduction in skeletal muscle mass: The reference values for percentage of appendicular lean mass (ALM) relative to total body weight is < 19.4% in women, < 25.7% in men, or a percentage of skeletal muscle mass (SMM) relative to total body weight of ≤ 27.6% in women and ≤ 37% in men.

  • A classification of severity level is also possible.

Clinical impact

Sarcopenia is associated with a multitude of negative outcomes. A number of meta-analyses showed an increased risk of mortality, although there was significant variation between the individual studies (2). A meta-analysis conducted by Xu et al. revealed that the risk of mortality in patients with sarcopenia is twice as high compared to individuals without sarcopenia (HR 2.00; [1.71; 2.34]). The observation period varied between 3 and 180 months. The risk of mortality was even higher among inpatients (HR 2.15; [1.76; 2.62]) and individuals in nursing homes (HR 2.84; [1.40; 5.73]) (3). The risk of falls (odds ratio [OR] 1.89; [1.33; 2.68]) and fractures (OR 1.71; [1.44; 2.03]) also rises in the case of sarcopenia (4, 21).

Sarcopenia affects not only motor function but is also associated with cognitive impairment (OR 1.75; [1.57; 1.95]) (22). A quarter (26%) of all individuals with dementia exhibit sarcopenia (23). Sarcopenia also correlates with depression and reduced quality of life (2). Generally speaking, individuals affected by sarcopenia have a lower quality of life (health-related quality of life, HRQoL) (standardized mean difference [SMD] -0.76; [–0.95; –0.57]) (24).

On average, sarcopenia patients take 1.39 more medications compared to individuals without sarcopenia (25) and have more hospital stays (2, 4, 26).

Individuals with sarcopenic obesity had a higher mortality rate (HR 1.51; [1.14; 2.02]) (27). A meta-regression found no significant differences between SO and sarcopenia in terms of cognitive impairments, falls, and cardiovascular diseases (28).

Prevention

Important preventive measures include:

• Regular physical activity and resistance training (12, 13)

• A balanced diet with adequate protein intake (at least 1.0 g/kg body weight/day) (12, 13).

Treatment of sarcopenia

Treatment is aimed at minimizing mobility restrictions and negative health outcomes. It should be patient-oriented (29). Individuals with sarcopenia should receive prompt and easy-to-understand information about their disease. Physical activity is the mainstay of treatment; dietary interventions can also be considered. Table 3 provides a summary of treatment recommendations (11–13, 30).

Table 3. Treatment recommendations for sarcopenia and sarcopenic obesity.

Intervention	Description
Physical activity	Strong recommendation
• Resistance training or multimodal training
• Consider a referral to physiotherapy or sport therapy for an individual training program
Increased protein intake or supplementation	Conditional recommendation
• Protein amount (g/kg body weight/day)   – General: 1.0–1.2 g   – In chronic diseases: 1.2–1.5 g   – In chronic kidney disease (at a glomerular filtration rate [GFR] of < 30 ml/min, without dialysis): 0.8 g
• Protein distribution of 25–30 g high-quality protein/meal
• Consider a referral for nutritional therapy in order to obtain an individual regimen to optimize nutrition
Adequate caloric intake*	Conditional recommendation
• In sarcopenia: energy intake of 24–36 kcal/kg body weight/day to cover requirements
Vitamin D supplementation in the case of vitamin D deficiency	Conditional recommendation

* There are currently no guidelines for sarcopenic obesity (SO).

A meta-analysis indicated that mild calorie restriction (20–25 kcal/kg body weight/day, or 90% of daily energy requirements)

and increased protein intake (> 1.2 g/kg body weight/day) decreased fat mass (FM) while preserving muscle mass (38).

Physical activity

This is the key element in the treatment of sarcopenia and SO and has positive effects on physical performance (31).

The international guidelines strongly recommend resistance training (RT) for the treatment of sarcopenia (11–13). In RT, the muscles are exercised against external resistance, for example, strength training with weights, resistance bands, or one’s own body weight. In general, one should seek to progressively increase exercise intensity (12). Detailed RT recommendations for sarcopenia patients are given in the eSupplement.

A network meta-analysis found that RT was associated with a positive effect on all components of sarcopenia. With RT, a mean difference was seen in:

• ASM of 0.90 kg [0.11; 1.75]

• Handgrip strength 2.58 [1.06; 4.07]

• Chair stand test -2.26 [–4.40; –0.42]

• Gait speed 0.28 [0.15; 0.41]

• TUG -1.69 [–3.10; –0.38].

The analysis included 30 RCTs, eight of which investigated the effect of RT alone and six the effect of RT combined with nutritional inventions. The RT intervention took place two or three times per week for an average of 1 h and lasted for between 8 and 36 weeks (median, 12 weeks) (32). RT had a positive effect on quality of life (SMD 1.11; [0.54; 1.68]) (33).

To improve adherence, RT can be offered either on its own or as part of a multimodal training program (12, 34). Additional balance and endurance training can be beneficial for a variety of physical functions (33, 35). Home-based interventions are a good alternative. They improved physical function with comparable drop-out rates (Table 4) (36). There is limited evidence for physical activity in SO, but it appears to be similar to that for sarcopenia (31, 37, 38).

Table 4. Non-pharmacological interventions (physical activity) in individuals with sarcopenia and their effect on physical performance (meta-analyses).

First author	Year	Ref.	Duration* (median)	Intervention	Main outcome	Comments
Li	2023	(36)	4.5 Months	Home-based exercise program (multimodal training)	Improvement in TUG: –1.41 s, 95% CI [−2.28; −0.54] as well as positive trend in GS: 0.12 m/s, 95% CI [0.00; 0.24]	RCTs; 2–7 × per week compared to passive controls
Ni	2022	(e11)	3 Months	Exercise training (multimodal training, RT and/or WBV)	Improvement in TUG: −1.24, 95% CI [−2.13; −0.36] as well as positive trend in GS: 0.14 m/s, 95% CI [−0.02; 0.30]	RCTs; 2–3 × per week compared to baseline
Lu	2021	(e12)	3 Months	Exercise training (multimodal training, RT, WBV)	Improvement in TUG: –0.66 s, 95% CI [−0.94; −0.38] and GS: 0.82 m/s, 95% CI [0.43; 1.21]	RCTs; 2–3 × per week compared to controls; including one non-randomized controlled trial
Zahng	2021	(e13)	3 Months	Exercise training (RT, multimodal training, WBV)	Improvement in TUG: –074 s, 95% CI [−0.48; −1.008] and GS: 0.56 m/s, 95 % CI [0.35; 0.82]	RCTs; 2–3 × per week compared to controls
Vlietstra	2018	(e14)	3 Months	Exercise training (RT and WBV)	Improvement in TUG: −1.67 s, 95% CI [−2.43; −0.91] as well as a positive trend in GS: 0.11 m/s, 95% CI [−0.01; 0.24]	RCTs; 2–3 × per week compared to controls
Yoshimura	2017	(e15)	3 Months	Multimodal training	Improvement in GS: 0.11 m/s, 95% CI [0.04; 0.19]	RCTs; 2 × per week compared to controls

GS, gait speed; CI, confidence interval; RCT, randomized controlled trial; RT, resistance training; s, seconds; m/s, meter per second;

TUG, Timed Up and Go test; WBV, whole body vibration training

*¹ Month corresponds to 4 weeks. This table shows meta-analyses of randomized controlled trials investigating the therapeutic effect of physical activity on physical performance in individuals with sarcopenia. A complete overview of all meta-analyses published between 01/2000 and 04/2024 on non-pharmaceutical interventions (such as physical activity and nutrition) and their effect on physical performance in individuals with sarcopenia can be found in eTable 3. None of the meta-analyses reported relevant adverse events.

Nutrition

There is a low level of evidence for nutritional recommendations in sarcopenia compared to physical activity, for which there is a moderate level of evidence (12, 39).

Current knowledge suggests that people aged over 65 years require more protein than do younger adults, with requirements being higher among those with chronic diseases (40). In order to optimize the benefit of protein supplementation, the timing and quality of the intake should be taken into consideration. Protein supplementation alone showed only limited positive results in clinical studies (e1). A meta-analysis found that whey protein supplementation (over an average period of 12–13 weeks) was associated with an increase in ASM (SMD 0.28 kg; [0.11; 0.45]) and gait speed (SMD 1.13 m/s; [0.82; 1.44]) (39). The combination of nutritional interventions with RT and balance training had a greater effect compared to training alone (33).

There is evidence to suggest that leucine supplementation increases muscle mass (e1). There is insufficient evidence that vitamin D supplementation alone is effective in older individuals, but it is recommended in the case of vitamin D deficiency (< 30 ng/mL) (12).

In SO, it is advisable not only to increase muscle strength and mass but also to reduce fat mass (FM). Calorie restriction should be approached with caution and in moderation due to the possible negative effects of weight loss (30). Although a low-calorie, high-protein diet reduces FM (MD –0.82 kg [–1.34; –0.30]) and preserves total skeletal muscle mass (MD 0.37 kg [–0.60; 1.35]), it does not improve physical performance (38). Increased protein intake alongside physical exercise also results in reduced FM (MD –0.80 kg [–1.32; –0.28]) (37).

Meta-analyses of randomized controlled studies investigating the therapeutic effect of non-pharmaceutical interventions on the physical performance of individuals with sarcopenia are presented in Table 4 and eTable 3. There is currently no approved pharmacological treatment for sarcopenia. Clinical studies are investigating the effect of a number of interventions (for example, myostatin inhibitors, growth hormones, and testosterone), none of which have conferred any relevant clinical improvement in physical performance to date (e2). Weight loss with GLP-1 receptor agonists or bariatric surgery in SO have not been sufficiently investigated in this age group (30).

eTable 3. Meta-analyses on non-pharmacological interventions for the treatment of sarcopenia and their effect on physical performance.

First author	Year	Ref.	Studies	n	Duration* (median)	Intervention	Main outcome	Comments
Physical activity
Li	2023	(36)	2	76	4.5 Months	Home-based exercise program (multimodal training)	Positive trend in GS: 0.12 m/s, 95% CI [0.00; 0.24]	RCTs; 2–7 × per week compared to passive controls
Li	2023	(36)	2	126	4.5 Months	Home-based exercise program (multimodal training)	Improvement in TUG: −1.41 s, 95% CI [−2.28; −0.54]	RCTs; 2–7 × per week compared to passive controls
Li	2023	(36)	3	151	3 Months	Home-based exercise program (multimodal training)	No significant change in GS: 0.03 m/s, 95% CI [−0.10; 0.16]	RCTs; 2–7 × per week compared to passive and active controls
Li	2023	(36)	2	144	3 Months	Home-based exercise program (multimodal training)	No significant change in TUG: −1.15 95% CI [−2.58; 0.28]	RCTs; 2–7 × per week compared to passive and active controls
Zaho	2022	(e22)	8	355	3 Months	RT	Improvement in GS: 1.50 m/s 95% CI [0.59; 2.40]	RCTs; median 2 × per week
Ni	2022	(e11)	6	332	3 Months	Exercise training (multimodal training, RT)	Positive trend in GS: 0.14 m/s, 95% CI [−0.02; 0.30]	RCTs; 4 used multimodal training, 2 RT, 2 × per weekcompared to baseline
Ni	2022	(e11)	5	252	3 Months	Exercise training (multimodal training, WBV)	Improvement in TUG: −1.24 s, 95% CI [− 2.13; −0.36]	RTCs; 3 used multimodal training, 2 WBV, 3 × per weekcompared to baseline
Huang	2022	(e23)	3	149	3 Months	Tai chi	No significant change in TUG: −0.86 s, 95% CI [−1.90; 0.17]	RCTs; 4 × per week
Huang	2022	(e23)	4	354	6–7 Months	Tai chi	No significant change in GS: 0.10 m/s, 95% CI [−0.20; 0.40]	RCTs; 4 × per week
Wang	2022	(e24)	7	342	3 Months	Exercise training (RT, multimodal training, WBV)	Improvement in TUG: −1.77 s, 95% CI [−2.11; −1.42]	RCTs; 4 used RT, 3 multimodal training, 1 WBV, 3 × per week,
Wang	2022	(e24)	14	867	3 Months	Exercise training (RT, multimodal training, WBV)	Improvement in GS: 0.88 m/s, 95% CI [0.49; 1.27]	RCTs; 8 used RT, 4 multimodal training, 2 WBV, 2–3 × per week
Lu	2021	(e12)	17	965	3 Months	Exercise training (multimodal training, RT, WBV)	Improvement in GS: 0.82 m/s, 95% CI [0.43; 1.21]	RCTs; 10 used multimodal training, 4 RT, 3 WBV, median 2–3 × per week
Lu	2021	(e12)	9	543	3 Months	Exercise training (multimodal training, RT, WBV)	Improvement in TUG: −0.66 s, 95% CI [−0.94; −0.38]	6 RCTs and one non-randomized controlled trial; 4 used multimodal training, 3 RT, 2 WBV, 3 × per week
Zahng	2021	(e13)	17	800	3 Months	Exercise training (RT, multimodal training, WBV)	Improvement in GS: 0.56 m/s, 95% CI [0.35; 0.82]	RCTs; 9 used RT, 7 multimodal training, 1 WBV, median 2 × per week
Zahng	2021	(e13)	9	397	3 Months	Exercise training (RT, multimodal training, WBV)	Improvement in TUG: 0.74 s, 95% CI [0.48; 1.00]	RCTs; 5 used RT, 3 multimodal training,1 WBV, median 3 × per week
Bao	2020	(e25)	10	563	3 Months	Exercise training (RT, multimodal training)	Improvement in GS: 0.44 m/s, 95% CI [0.26; 0.61]	RCTs; 5 used RT. 5 multimodal training. median 2 × per week compared to baseline
Bao	2020	(e25)	6	330	3 Months	Exercise training (RT, multimodal training, WBV)	Improvement in TUG: −0.97 s, 95% CI [−1.22; −0.72]	RCTs; 4 used RT, 1 multimodal training, 1 WBV, on average 3 × per week compared to baseline
Wu	2020	(e26)	2	95	10 Weeks	WBV	Improvement in TUG: −0.83 s, 95% CI [−1.56; −0.11]	RCTs; median 3 × per week
Vlietstra	2018	(e14)	4	222	3 Months	Exercise training (RT and WBV)	Positive trend in GS: 0.11 m/s, 95% CI [−0.01; 0.24]	RCTs; 2 used RT, 1 WBV, 2–3 × per week
Vlietstra	2018	(e14)	2	104	3 Months	Exercise training (RT and WBV)	Improvement in TUG: −1.67 s, 95% CI [−2.43; −0.91]	RCTs; 1 used RT, 1 WBV, 2–3 × per week
Yoshimura	2017	(e15)	3	397	3 Months	Multimodal training	Improvement in GS: 0.11 m/s, 95% CI [0.04; 0.19]	RCTs; multimodal training, 2 × per week
Nutrition
Li	2024	(39)	2	187	Between 6 weeks and 8 months	Whey protein supplementation	Improvement in GS: 1.13 m/s, 95% CI [0.82; 1.44]	RCTs; whey protein with vitamin D
Li	2024	(39)	5	687	6 Months	Whey protein supplementation	No significant change in SPPB: 0.38 points, 95% CI [−0.16; 0.92]	RCTs
Zahng	2024	(e27)	9	797	3 Months	Traditional Chinese medicine	Improvement in 6-m walking speed: 1.34, 95% CI [0.60; 2.08]	RCTs
Zahng	2024	(e27)	3	270	3 Months	Traditional Chinese medicine	Improvement in SPPB: 1.50 points, 95% CI [1.05; 1.95]	RCTs
Li	2023	(36)	2	116	4.5 Months	Home-based nutritional interventions	No significant change in GS: 0.05 m/s, 95% CI [−0.01; 0.11]	RCTs; multiple nutrients such as protein, vitamin D, leucine,vitamin C, vitamin E, and hydroxy beta-methylbutyrate; compared to passive control
Li	2023	(36)	4	508	4.5 Months	Home-based nutritional interventions	Improvement in GS: 0.05 m/s, 95% CI [0.02; 0.09]	RCTs; multiple nutrients such as protein, vitamin D, leucinevitamin C, vitamin E, and hydroxy beta-methylbutyrate; compared to passive and active controls
Kamińska	2023	(e28)	7	1105	12 Months	Whey protein supplementation	No significant change in SPPB: 0.034 points, 95% CI [−0.071; 0.14]	RCTs; median 40 g whey protein + vitamin D
Prokopidis	2022	(e29)	4	444	9 Months	Vitamin D	Significant decrease in SPPB score: −0.23 points, 95% CI [−0.40; −0.06]	RCTs; median 1200 IU daily
Prokopidis	2022	(e29)	3	800	9 Months	Vitamin D	No significant change in TUG: 0.07 s, 95% CI [−0.08; 0.22]	RCTs; around 1600–1700 IU daily
Lee	2022	(e30)	5	655	3 Months	Leucine-rich protein supplements	Positive trend in PP: 0.788, 95% CI [−0.01; −1.586]	RCTs; PP = physical performance, as a combined outcome of SPPB, GS, and balance, median of 6 g leucine per day, usually with a mixture of other proteins; where appropriate, withmicronutrients
Gkekas	2021	(e31)	5	520	3 Months	Vitamin D	No significant change in GS: 0.088 m/s, 95% CI [−0.042; 0.303]	RCTs; median vitamin D 800 IU daily, all studies usedadditional leucine, protein, or BBCA
Yoshimura	2017	(e15)	3	422	3 Months	Nutrition	No significant change in GS: −0.01 m/s, 95% CI [−0.06; 0.04]	RCTs; essential amino acids—supplements and/or teacatechins
Combination of physical activity and nutrition
Whaikid	2024	(e32)	2	91	14 Weeks	Protein supplementationcombined with RT	No significant change in GS: 0.04 m/s, 95% CI [−0.37; 0.45]	RCTs; protein or essential amino acid supplementation
Yoshimura	2017	(e15)	3	212	3 Months	Exercise and nutrition	Improvement in GS: – 0.07 m/s, 95% CI [−0.13; 0.00]	RCTs; versus exercises
Yoshimura	2017	(e15)	3	211	3 Months	Exercise and nutrition	No significant change in GS: 0.06 m/s, 95% CI [−0.01; 0.14]	RCTs; versus nutrition

GS, gait speed; PP, physical performance; RT, resistance training; s, seconds; m/s, meter per second; TUG, Timed Up and Go test; SPPB, short physical performance battery;

WBV, whole body vibration training; * 1 Month corresponds to 4 weeks.

This table presents meta-analyses of randomized controlled trials investigating the therapeutic effect of non-pharmaceutical interventions (such as physical activity and nutrition) on physical performance in individuals with sarcopenia. Only meta-analyses published between 01/2000 and 04/2024 are presented. None of the meta-analyses reported relevant adverse events.

Conclusion

Sarcopenia and SO are highly prevalent diseases in advanced age. This may be attributable in part to age-related changes in body composition, such as the reduction in muscle protein synthesis as well as the loss of muscle strength and mass (5, e3, e4). Sarcopenia already begins to develop in early life (e5). In individuals of middle age, the decline in physical performance is due more to a sedentary lifestyle than to biological aging (e6). A 10-day period of bed rest causes a loss in muscle mass of 5% and in muscle strength of around 10% in younger healthy adults (e7). Sarcopenia is also observed more frequently in individuals with chronic diseases (2).

The diagnostic criteria for both diseases have already been revised a number of times in the past. The diagnosis is made on the basis of reduced muscle strength and mass, together with increased fat mass for sarcopenic obesity (5, 8). The detection of reduced muscle strength is an indication to initiate treatment (8).

These diseases lead to a wide range of negative outcomes for those affected, as well as high healthcare costs (2). Early detection and prompt treatment could reduce these negative effects. Treatment primarily comprises physical activity and aims to preserve and improve muscle strength and physical performance (11–13). RT improves muscle strength and mass as well as physical performance (34). It also increases muscle protein synthesis and builds up type I and II muscle fibers. This may explain the improvements in muscle strength and endurance (e8). Due to the paucity of evidence, nutritional interventions are recommended to only a limited extent (11–13).

Despite its considerable clinical and social relevance, many treating physicians are unfamiliar with sarcopenia (e9, e10). It remains the case that structured screening and standardized diagnosis followed by treatment initiation rarely occur in clinical routine. There are currently no national German guidelines on the diagnosis and treatment of sarcopenia or SO, with the exception of a short section in the guideline of the German Society for Nutritional Medicine (Deutsche Gesellschaft für Ernährungsmedizin, DGEM).

A systematic and comprehensive approach involving screening, diagnosis, and treatment can make a major contribution to the improvement and maintenance of quality of life in those affected, as well as promoting healthy aging.

Questions on the article in issue 5/2025:

The Diagnosis and Treatment of Sarcopenia and Sarcopenic Obesity

The submission deadline is 06.03.2026. Only one answer is possible per question.

Please select the answer that is most appropriate.

Question 1

What is primary sarcopenia?

1. Loss of muscle mass and strength due to systemic inflammation.

2. Age-related loss of muscle mass and strength.

3. Loss of muscle mass and strength due to physical inactivity.

4. Loss of muscle mass and strength due to malnutrition.

5. Loss of muscle mass and strength due to impaired transmission of impulses between nerves and muscles

Question 2

What are common causes of secondary sarcopenia?

1. Systemic inflammation and low physical activity

2. Hormonal imbalance

3. High protein and energy intake

4. Genetic factors

5. Polypharmacy

Question 3

What is meant by the clinical picture of sarcopenic obesity?

1. A combination of high fat mass and low muscle strength/mass

2. A combination of high muscle mass and low fat mass

3. A disorder caused only by aging

4. Increased fat mass in old age

5. A disease caused solely by genetic predisposition

Question 4

What forms an important part of sarcopenia screening in individuals aged 65 years and over?

1. Body mass index

2. SARC-F questionnaire

3. The Timed Up and Go test

4. Handgrip strength

5. Bioelectric impedance analysis

Question 5

What is the minimum SARC-F point score at which screening for sarcopenia is considered positive?

1. ≥ 1 Point

2. ≥ 2 Points

3. ≥ 3 Points

4. ≥ 4 Points

5. ≥ 5 Points

Question 6

In the diagnostic work-up of sarcopenic obesity, how is the relative increase in fat mass and the relative reduction in skeletal muscle mass usually measured?

1. Body mass index

2. SARC-F

3. Handgrip strength

4. Waist circumference

5. DXA or BIA

Question 7

Which of the following statements regarding the clinical effects of sarcopenia does not apply?

1. The risk of mortality among patients with sarcopenia is twice that of individuals without sarcopenia.

2. The quality of life of individuals with sarcopenia is unchanged.

3. On average, individuals with sarcopenia take more medications and have more frequent stays in hospital compared to individuals without sarcopenia.

4. The risk of falls and fractures is higher in individuals with sarcopenia.

5. Sarcopenic obesity is associated with increased mortality.

Question 8

Which of the following elements is crucial in the prevention of sarcopenia in old age?

1. Regular physical activity and resistance training

2. Physical rest

3. Taking vitamin D supplements

4. High-carbohydrate diet

5. Stress reduction through autogenic training

Question 9

For which of the following measures is the evidence strongest in the treatment of sarcopenia?

1. Mild calorie restriction

2. Increased protein intake

3. Low-carbohydrate diet

4. Vitamin D supplementation

5. Resistance training

Question 10

What is the recommended protein intake (g/kg body weight/day) for individuals with sarcopenia and chronic diseases?

1. < 0.5 g

2. 0.5–1.0 g

3. 1.2–1.5 g

4. 5–8 g

5. 25–30 g

Participation is only possible online: cme.aerzteblatt.de