The Need for Harmonized Diagnostic Criteria for Sarcopenia after the AWGS 2025 Consensus

The recently published 2025 consensus of the Asian Working Group for Sarcopenia (AWGS) represents a significant milestone in the field.¹) Importantly, this update should be interpreted in the broader context of the Global Leadership Initiative on Sarcopenia (GLIS), which has sought to establish a globally harmonized conceptual definition of sarcopenia.^2-4) GLIS emphasizes reduced skeletal muscle mass and reduced muscle strength as core components of sarcopenia, while physical performance and mobility limitations are more appropriately considered clinically meaningful outcomes or functional consequences.⁴) The AWGS 2025 consensus was developed with consideration of the GLIS conceptual definition, particularly given that some AWGS members also participated in GLIS. The most notable feature of this updated consensus is the attempt to simplify the diagnostic process, whereby sarcopenia can be diagnosed when both low skeletal muscle mass and low muscle strength are present. While this streamlined framework offers practical advantages for clinical implementation across diverse Asian healthcare settings, it simultaneously opens important avenues for critical discussion regarding the implications of diagnostic simplification in sarcopenia management. Nevertheless, the implementation of this framework also raises several important questions that merit further discussion.

First, the apparent simplification of diagnostic criteria should not be viewed as a retreat from multidimensional assessment, but rather as part of an evolving attempt to distinguish the core definition of sarcopenia from its clinical consequences. Since the publication of the 2010 consensus of the European Working Group on Sarcopenia in Older People (EWGSOP), most subsequent diagnostic frameworks have been largely inspired by its core principles.^1,5-9) These frameworks emphasize a multidimensional assessment of sarcopenia based on skeletal muscle mass, muscle strength, and physical performance. Nearly all existing consensus definitions have incorporated at least two of these three domains. As illustrated in Fig. 1, the evolution of sarcopenia diagnostic criteria reflects various combinations of these components over time. This raises a fundamental question: with numerous criteria coexisting, how can clinicians and researchers maintain both conceptual consistency and practical applicability? Although sarcopenia has been recognized as a disease entity in the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) since 2016, a universally accepted and operationally harmonized diagnostic standard has yet to be established.¹⁰)

Fig. 1.

Components and evolution of international consensus definitions for sarcopenia (2010–2025). EWGSOP, European Working Group on Sarcopenia in Older People; IWGS, International Working Group on Sarcopenia; FNIH, Foundation for the National Institutes of Health Sarcopenia Project; AWGS, Asian Working Group for Sarcopenia; SDOC, Sarcopenia Definition and Outcomes Consortium.

Beyond issues of conceptual consistency, diagnostic accessibility represents another major challenge in sarcopenia care. In the AWGS 2025 consensus, skeletal muscle mass and muscle strength are retained as core diagnostic components. However, accurate assessment of skeletal muscle mass remains difficult in routine clinical settings. As noted by GLIS, current studies on the association between sarcopenia and health outcomes have largely been conducted in developed countries, possibly due to the limited availability of dual-energy X-ray absorptiometry (DXA) or bioelectrical impedance analysis (BIA) devices in other settings.²)

In many regions, including China, DXA is rarely used in routine clinical practice, and universally accepted cutoff values for assessing skeletal muscle mass remain difficult to establish.¹¹) Its results may also be influenced by hydration status, fat infiltration, device differences, and analytic algorithms. While offering greater accessibility, the reliability of BIA is significantly limited by variability due to differences in devices, measurement protocols, and patient fluid levels.⁸) To address the difficulty in assessing skeletal muscle mass, some investigators have proposed equations to estimate appendicular skeletal muscle mass (ASM). However, the accuracy of these equations remains uncertain.¹²) These measurement issues are particularly important when diagnostic thresholds are applied across different ethnic, cultural, nutritional, and regional populations. Besides, the exclusion of physical performance from the conceptual definition remains open to debate and is not yet supported by abundant high-quality evidence. In the GLIS Delphi process, the statement that physical performance should be included in the conceptual definition of sarcopenia received agreement rates of 79.4% in the first round (mean score, 7.3±2.8) and 79.8% in the second round (mean score, 7.5±2.6), both narrowly below the prespecified 80% threshold.⁴) From a methodological perspective, a difference of only 0.2% led to a binary change in the final conclusion, although such a small margin may not represent a clinically or statistically meaningful distinction. In addition, academic professionals accounted for 71% of Delphi participants, whereas frontline health professionals accounted for only 22%, which may have influenced the balance between theoretical importance and practical accessibility. Because experts were also asked to assume that all measurement tools were available under ideal conditions, the process may have underweighted feasibility differences across real-world clinical settings.

From a practical clinical perspective, the criteria proposed by the Sarcopenia Definition and Outcomes Consortium (SDOC) in 2020 may better align with real-world practice.⁷) The SDOC framework does not require the assessment of skeletal muscle mass, instead focusing on muscle strength and physical performance. Although this approach differs from the GLIS and AWGS 2025 emphasis on muscle mass and strength as core conceptual components, it highlights a persistent clinical problem: a diagnostic standard can only improve care if it can be implemented reliably in real-world practice. Simple physical performance measures, such as gait speed and the Short Physical Performance Battery, may therefore remain especially valuable in primary care and resource-limited environments. Skeletal muscle health plays a central role in glucose and lipid metabolism and contributes to the pathogenesis of multiple chronic diseases.¹³) When drawing parallels with the diagnosis of metabolic disorders, clinicians do not quantify pancreatic beta-cell number to diagnose diabetes, nor do they assess vascular structure to diagnose hypertension, or lipid synthesis pathways to diagnose dyslipidemia. Similarly, when a disease lacks both diagnostic uniformity and practical accessibility, clinical feasibility should remain a key consideration.

In summary, the central issue is not whether sarcopenia diagnosis should be simplified, but how diagnostic criteria can balance scientific validity, clinical feasibility, and global harmonization. AWGS 2025 should be recognized as a constructive attempt to align Asian clinical practice with the GLIS conceptual framework while responding to the needs of Asian populations. At the same time, further work is needed to clarify measurement methods, establish population-appropriate reference ranges, and ensure that results remain comparable across regions and studies. Sarcopenia should not remain a condition confined to a small circle of geriatric specialists, but rather should become as recognizable and manageable as hypertension or diabetes. Through population-level education and practical diagnostic strategies, the promotion of muscle health may contribute meaningfully to healthy aging at a societal scale.