Table 3.

Comparing sarcopenia definition and diagnosis across guidelines.

Guideline	Definition	Strengths (Aligned with South Asian perspective)	Limitations (Not aligned with South Asian perspective)
International Guidelines
EWGSOP [41]	“The EWGSOP recommends using the presence of both low muscle mass and low muscle function (strength or performance) for the diagnosis of “with diagnosis based on documentation of low muscle mass with either low muscle strength or low physical performance	•• Along with the general definition further defines conceptual stages of sarcopenia as ‘presarcopenia’, ‘sarcopenia’ and ‘severe sarcopenia’ •Wide variety of tools assessed	•Applicable to only community dwelling older adults •Lack of biomarkers for diagnosing •No recommendations for Vitamin D supplementation
EWGSOP2 [46]	“In its 2018 definition, EWGSOP2 uses low muscle strength as the primary parameter of sarcopenia; muscle strength is presently the most reliable measure of muscle function. Specifically, sarcopenia is probable when low muscle strength is detected. A sarcopenia diagnosis is confirmed by the presence of low muscle quantity or quality. When low muscle strength, low muscle quantity/quality and low physical performance are all detected, sarcopenia is considered severe.”	•Provision of hard cut-offs for diagnosis based on European data and relevant to community and clinical practice •More Importance to muscle strength than muscle mass as main determinant of sarcopenia •Clear algorithm for sarcopenia screening and diagnosis: F-A-C-S tool •Includes secondary sarcopenia and sarcopenic obesity	•No single universal tool for measuring various parameters like muscle mass or function •Does not include biomarkers for diagnosis •Vitamin D supplementation mentioned for frailty not sarcopenia
ICFSR [47]	Evidence based guideline for screening, diagnosis and management; no definition proposed General definition of sarcopenia is accepted: “Sarcopenia is defined as an age-associated loss of skeletal muscle function and muscle mass, and is common in older adults”	•Endorses all international operational tools recommended by EWGSOP), FNIH, IWGS, and AWGS. •Acknowledges- cut-off points tailored according to population characteristics •Recommend rapid screening using gait speed or SARC-F •Low grade conditional recommendation for using DXA, CT and MRI for LBM •Recommendations considered patient preference/values and cost-effectiveness •Protein supplement and/or protein rich diet recommended •Acknowledges need to include secondary sarcopenia	•Recommendations not applicable for secondary sarcopenia •Recommendations only for community setting •Low grade conditional recommendation for using clinical judgment only when DXA, CT and MRI for LBM are not available •LEMS not covered •No recommendations for Vitamin D supplementation
FNIH [44]	No definition proposed	•Recommendations based on pooled sample of 26,625 participants (community dwellers) •Recognizes sarcopenia secondary to other causes	•Recommendations only for community setting as data is collated from 9 sources of community dwelling adults; not applicable in healthcare and nursing care settings • •Ethnic differences not taken care of • No recommendations for treatment •Does not include biomarkers for diagnosis
International Working Group on Sarcopenia (IWGS) [42]	“Sarcopenia is the age-associated loss of skeletal muscle mass and function. Sarcopenia is a complex syndrome that is associated with muscle mass loss alone or in conjunction with increased fat mass. The causes of sarcopenia are multifactorial and can include disuse, changing endocrine function, chronic diseases, inflammation, insulin resistance, and nutritional deficiencies. While cachexia may be a component of sarcopenia, the two conditions are not the same.”	•Recognize both lean mass and fat mass (sarcopenic obesity) •Recommends easy to use methods to diagnose sarcopenia •Endorse ALM/Ht2 to diagnose sarcopenia	Narrow scope •Recommendations only for defining sarcopenia •No recommendations for management
Position Statements of the Sarcopenia Definition and Outcomes Consortium (SDOC) [49]	“The Panel agreed that both weakness defined by low grip strength and slowness defined by low usual gait speed should be included in the definition of sarcopenia.”	“Identified grip strength – either absolute or scaled to measures of body size – as an important discriminator of slowness” Does not recommend the use lean mass measured by DXA in the definition of sarcopenia	No recommendations for secondary sarcopenia
Asian Guidelines
AWGS 2014 [43]	Both define sarcopenia as “age-related loss of muscle mass, plus low muscle strength, and/or low physical performance” without reference to comorbidity	•Separate screening guidelines for community settings and for specific chronic conditions in healthcare settings •Acknowledges Asia is made up of many ethnicities and thus South Asia is different from East Asia	•Mentions LEMS (quadriceps strength) but no recommendation for it •Recommendations based on Eastern Asia ethnicity/studies •No focus on secondary sarcopenia •No recommendations for Vitamin D supplementation
AWGS 2019 Consensus Update on Sarcopenia Diagnosis and Treatment [48]		•Algorithm based approach •Introduction of quick screening methods like calf circumference, SARCF and SARC-CalF for case findings •Introduction of severe sarcopenia category in line with EWGSOP2 •Different approach for different settings. •Removal of the term Pre-sarcopenia because its lack of evidence in prognostication •Introduction of term ‘possible sarcopenia’ based on the low muscle strength with or without low muscle performance to be used in community settings without means for muscle mass measurement.	•Endorsed DEXA and multifrequency BIA for measuring muscle mass measurement. Many readily available tools like MRI and CT that have shown promise not included •Role of biomarkers not discussed. •No focus on secondary sarcopenia
JSH [45]	No definition proposed	•Includes secondary sarcopenia (mainly liver related causes) •Stressed on PEM	•No focus on anthropometrics
Clinical Practice Guideline for Sarcopenia from Japan [39]	“Sarcopenia is generally defined as a decrease in skeletal muscle mass and muscle strength or physical function, such as gait speed, observed in elderly individuals.”	•Includes secondary causes •Includes sarcopenic obesity •Considers evidence from international guidelines	•No cut-off values available for diagnosis •No focus on anthropometrics
South Asian Consensus		Strengths (Can be applied globally)	Limitations (for global use)
The SWAG-SARCO 2021	The group defines sarcopenia as a condition in which any two of the following parameters are suboptimal, as assessed by clinical, biochemical and/or imaging modalities: muscle function, muscle strength and muscle mass	•Algorithm based easy, practical and economic approach for screening and diagnosing (5 S pathway: Suspect, Screening, Secondary sarcopenia (including concomitant therapy), Severity (muscle strength, function, and/or mass), and Shared decision making Recognizes muscle strength and function over muscle mass •Includes secondary sarcopenia (including concomitant medications) and sarcopenic obesity •Includes biomarkers for diagnosis •Introduces the concept of osteo- arthro-muscular triad as recognizes that muscle cannot function in isolation •Wider scope: applicable to community dwelling, clinical and hospital practice •Practical guidance for management	•Cut-offs for various measurements more applicable to South Asian ethnicity (some cut-offs are globally applicable) •Nursing care facilities for elderly not included as concept not common in South Asia

AWGS, Asian Working Group for Sarcopenia; EWGSOP, European Working Group on Sarcopenia in Older People; EWGSOP2, Revised European Working Group on Sarcopenia in Older People; FNIH, Foundation for the National Institutes of Health; ICFSR. International Clinical Practice Guidelines for Sarcopenia; IWGS, International Working Group on Sarcopenia; JSH, Japanese Society of Hematology; PEM, protein energy malnutrition; SWAG-SARCO, South Asian Working Action Group on Sarcopenia.