Beaudart et al.

Archives of Public Health 2014, 72:45

[Link] ARCHIVES OF PUBLIC HEALTH

COMMENTARY Open Access

Sarcopenia: burden and challenges for public

health
Charlotte Beaudart1,2*, René Rizzoli3, Olivier Bruyère1,2,5, Jean-Yves Reginster1,4 and Emmanuel Biver3

Abstract
Sarcopenia, operationally defined as the loss of muscle mass and muscle function, is a major health condition associated
with ageing, and contributes to many components of public health at both the patient and the societal
levels. Currently, no consensual definition of sarcopenia exists and therefore it is still a challenge to establish
the actual prevalence of sarcopenia or to establish the direct and indirect impacts of sarcopenia on public
health. Anyway, this geriatric syndrome represents a huge potential public health issue because of its multiple
clinical and societal consequences. Moreover, all these aspects have an impact on healthcare costs both for
the patient and the society. Therefore, the implementation of effective and broadly applicable preventive and
therapeutic interventions has become a medical and societal challenge for the growing number of older
persons affected by sarcopenia and its disabling complications.
Keywords: Sarcopenia, Public health, Epidemiology, Consequences, Diagnosis

Background [5-11]. These definitions differ from each other in regards

Thanks to social, health and technological progress, the to muscle mass indicators (ratio of appendicular lean mass
proportion of older people in the age pyramid is increas- over height squared, ALM/ht2, or over body mass index,
ing all over the world. According to the World Health ALMBMI), the cutpoints for slow gait speed and whether
Organisation, in 2050 there should be at least 2 milliards or not they include a measure of weakness (Table 1).
of people aged 65 years or older, compared to 600 million However, there is actually no universal consensus for an
today. The life expectancy is also increasing and is esti- operational definition of sarcopenia, which is an important
mated around 80 years in industrial countries [1]. The issue for public health.
aging process is responsible of many changes in body A wide range of techniques can be used to measure
composition including a loss of skeletal muscle mass. the different components of sarcopenia [12]. Three tech-
From the age of 25, there is a progressive decrease in the niques can be used for the measurement of appendicular
size and number of muscle fibres resulting in a loss of lean mass: body imaging techniques, bio impedance ana-
about 30% of muscle mass at the age of 80 [2]. Beyond lysis and anthropometry measures. In research, the two
some defined threshold, this age-related loss of muscle gold standards are the computed tomography (CT-scan)
mass is characterized as abnormal. To characterize this and the magnetic resonance imaging (MRI). However,
phenomenon, the term “sarcopenia” was firstly introduced because of the high costs and the limited access to this
by Irwin Rosenberg [3]. The definition of sarcopenia was kind of equipment, the European Working Group on
then enriched with scientific and technological advances Sarcopenia in Older People (EWGSOP) [8] recommends
and gradually evolved to incorporate the notions of de- in clinical practice, first the use of either dual energy X-
creased muscle mass [4], then of decreased muscle func- ray absorptiometry (DXA) or, as a portable alternative to
tion (low muscle strength or low physical performance) DXA, the bioelectrical impedance analysis (BIA). Despite
their easy use in clinical practice, the anthropometric
* Correspondence: [Link]@[Link] measures are not recommended for the diagnosis of sar-
1
Department of Public Health, Epidemiology and Health Economics, copenia because these measures are not validated in
University of Liège, Avenue de l’Hôpital 3 – CHU B23, Liège 4000, Belgium
2
Support Unit in Epidemiology and Biostatistics, University of Liège, Liège, older people and are, therefore, vulnerable to error. Sev-
Belgium eral techniques are also available for the measurement of
Full list of author information is available at the end of the article

© 2014 Beaudart et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License ([Link] which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver ([Link] applies to the data made available in this article,
unless otherwise stated.
 [Link]
Beaudart et al. Archives of Public Health 2014, 72:45
Table 1 Proposed operational definitions of sarcopenia
Criteria Muscle mass Muscle function
Muscle strength Physical performance
Baumgartner criteria [4] Sarcopenia ASM/ ht2 > 2 SD below young healthy mean x x
European Society for Clinical Nutrition and Sarcopenia Percentage of muscle mass ≥2 SD below mean in x Gait speed: <0.8 m/s or Reduced
Metabolism Special Interest Groups (ESPEN-SIG) [7] young adults of the same sex and ethnic background performance in any functional test
(individuals aged 18–39 years in the NHANES III cohort) used for comprehensive geriatric
assessment
European Working Group on Sarcopenia in Older Sarcopenia ALM/ht2 Grip strength OR Gait speed: <0.8 m/s
People (EWGSOP) [8]
- Men: ≤7.23 kg/m2 - Men: <30 kg
Severe - Women: ≤5.67 kg/m2 - Women: <20 kg AND
sarcopenia
International Working Group on Sarcopenia Sarcopenia ALM/ht2 x Gait speed: <1.0 m/s
(IWGS) [9]
- Men: ≤7.23 kg/m 2

- Women: ≤5.67 kg/m2

Society of Sarcopenia, Cachexia and Wasting Sarcopenia with ALM/ht2 > of 2 SD below the mean of healthy persons x Gait speed: ≤1.0 m/s or Walking
Disorders [10] limited mobility aged 20–30 years of the same ethnic group distance < 400 m during a 6-min walk
Foundation of NIH Sarcopenia Project [11] Weakness and ALMBMI Grip strength x
low lean mass
- Men: <0.789 - Men: <26 kg
Slowness with - Women: <0.512 - Women: <16 kg AND Gait speed: ≤0.8 m/s
weakness and
low lean mass
ASM/ ht2 = ratio of appendicular skeletal muscle mass over height squared; ALM/ht2 = ratio of appendicular lean mass over height squared; ALMBMI = ratio of appendicular lean mass over body mass index; SD
standard deviation.

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muscle strength. Three techniques could potentially be skin compared to Caucasian people. Recently, a systematic
used for the diagnosis of sarcopenia: handgrip strength, review [23] on the prevalence of sarcopenia has been pub-
knee flexion or knee extension strength and the measure- lished. It indicates that the prevalence of EWGSOP-defined
ment of peak expiratory flow. In clinical research, the sarcopenia is 1-29% for older adults living in community.
handgrip strength is the most widespread method. Indeed, The differences in prevalence seem attributable to the age
this method does not require any special equipment, has of the population and the methods of assessment used but
been documented as a good marker of physical perform- also to the cut-offs used for the diagnosis.
ance among community-dwelling older people and is well Prevalence of sarcopenia could also differ depending
correlated with leg strength [13,14]. Finally, the physical on the definitions used for the diagnosis of sarcopenia,
performance can be measured by the “short physical per- as recently highlighted in the comparison of the FNIH
formance battery test (SPPB)”, by the “usual gait speed” or criteria with the International Working Group and the
by the “timed up and go test” or “stair climb power test”. European Working Group for Sarcopenia in Older Persons
The EWGSOP [8] recommends the use of either the usual [11]. In 2013, Batsis et al. [24] compared eight definitions
gait speed, measured on a 4-meter distance or the SPPB of sarcopenia and found a prevalence ranging from 4.4%
test [15] which is a composite measuring walk speed, to 94% across definitions. In 2013, Bijlsma et al. found that
balance and the ability to stand up 5 times from a chair. the prevalence of sarcopenia with different diagnostic cri-
Different cut-offs have been developed by the EWGSOP teria ranged from 0% to 20.8% in the lowest age category
for each variable and could be applied for the diagnosis of (below 60 years), from 0% to 31.2% in the middle (60 to
sarcopenia. Recently, the Foundation of NIH Sarcopenia 69 years) and from 0% to 45.2% in the highest (above
Project proposed recommendations for cut-off points 70 years) [25]. As expected, studies using muscle mass as
for weakness and low lean mass definitions aiming to single criterion of diagnosis revealed a higher prevalence
provide an operational definition for sarcopenia. It was of sarcopenia than studies based on the EWGSOP consen-
recommended to assess muscle strength by grip strength sus algorithm. The choice of cut-off limits applied could also
with cutpoints <26 kg in men and <16 kg in women, influence the prevalence of sarcopenia. This is confirmed in
and low lean mass by appendicular lean mass ad- a study (performed in our Department, in press) showing
justed to BMI, with respective cutpoints <0.789 kg/m2 that the prevalence of sarcopenia can vary from 9.25% to
and <0.512 kg/m2 [16]. 18% depending on the cut-offs used. This same study also
Given the variability in the definitions of sarcopenia, it shows the importance of the diagnostic tool chosen for the
is still a challenge to establish the actual prevalence of measurement of muscle mass, muscle strength and physical
sarcopenia according to age and gender and to assess performance. Depending on the tool used, the prevalence
the direct and indirect impacts of sarcopenia on public of sarcopenia can range from 8.4% to 27.6%.
health. The aim of this review is to discuss, both broadly Sarcopenia is also often related to multiple pathologies
and specifically, the public health implication of sarcope- and comorbidities which can also compromise the meas-
nia and its association with objectives health-related out- urement of its prevalence. Some authors are actually inter-
comes such as falls, fractures, admission in nursing homes ested in sarcopenia in combination with another health
or mortality. issue, like osteoporosis, osteopenia, obesity, type II diabetes
mellitus, breast cancer, etc. The prevalence of sarcopenia is
Discussion systematically higher in subjects presenting another health
Epidemiology of sarcopenia condition than in healthy subjects. Sarcopenia could be, in
Sarcopenia is very common in older people. Currently it this case, considered as one consequence of this health
is still a public health challenge to establish a prevalence problem.
of sarcopenia. Indeed, this estimated prevalence depends This confused state and the current impossibility of estab-
on the type of studied population. A large number of lishing a clear prevalence of sarcopenia makes comparisons
studies have assessed the prevalence of sarcopenia within between studies difficult and thus represents an important
a cohort of adult subjects and this estimated prevalence public health issue. Moreover, the various values for the
could range from 0.1% to 85.4% according to patients’ prevalence of sarcopenia found across studies are probably
characteristics [17-22]. Globally, a higher prevalence of associated with different characteristics of sarcopenic sub-
sarcopenia is often observed in men, in elderly subjects, jects which could compromise the implementation of per-
in subjects living in nursing home, in subjects having a tinent therapeutic strategies in the field of sarcopenia.
low body mass index but also in subjects having a low
educational level. The prevalence of sarcopenia seems Consequences of sarcopenia: Indirect impact on public
also to differ according to ethnicity. Indeed, a higher health
prevalence of sarcopenia is observed in Asian people Many consequences of sarcopenia are prognostic indica-
and a lower prevalence is observed in people with dark tors of public health burden, such as the development of
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physical disability, nursing home admission, depression, homes, or mortality. Future researches are clearly needed
hospitalization, and even mortality [26]. In particular, in this field to clarify which operational definition of
sarcopenia is associated with poor physical performance, sarcopenia should be integrated in clinical practice to
functional decline and physical disability [22,26]. Sarco- diagnose and target sarcopenia and its impact on public
penia predicts loss of independence for daily life activ- health.
ities in elderly men and women [27,28], and also affects
gait speed or regularity. Leg lean mass has been identi- Public health costs of sarcopenia
fied as an independent predictor of the level of mobility Disability is associated with an increased risk of hospitalization
impairment assessed by the SPPB test [29]. Ability to and nursing home placement, increased home healthcare
walk is an obvious determinant of subsequent disability, and, obviously, health care expenditure. Given the effect
mortality, and health care costs [30]. Sarcopenia is also of sarcopenia on disability, public health costs of sarcope-
associated with falls, a well known issue regarding the nia are expected to be high. Currently, economic data on
risk of fracture and disabilities (odds ratio for fall in the sarcopenia are very poor. Only one study has currently re-
sarcopenia group relative to the normal group: 4.42 ported the healthcare costs of sarcopenia in the United
(95% CI 2.08-9.39) in men and 2.34 (95% CI 1.39-3.94) States [46]. Those estimates have taken into consideration
in women) [31]. the direct costs of sarcopenia which raised, in 2000, to
Sarcopenia is also associated with many comorbidities $18.5 billion, $10.8 billion in men and $7.7 billion in
which have a major impact on public health. As occur- women. These costs are represented by hospitalization,
ring concomitantly with age-related bone loss, sarcope- nursing home admissions and home healthcare expend-
nia coexists with osteoporosis and may increase fracture iture. In 2000, this amount represented about 1.5% of
risk, potentially directly via crosstalk between muscle total health expenditure in the United States. It must
and bone tissues [32,33] and indirectly via increase of be added that, in addition to disability, sarcopenia is
risk of falling [34,35]. Most of endocrine diseases (diabetes, associated with multiple comorbidities and may also
hypogonadism, hypercortisolism…) as well as obesity, or have effect on osteoporosis [47], obesity [48] and type
chronic kidney disease [34], are associated with sarcopenia II diabetes mellitus [49]. Whith these comorbidities
independently of age-related muscle loss, which may be an associated healthcare costs taken into account, the
underlying mechanism by which chronic diseases cause economic burden of sarcopenia may probably be even
physical disability [36]. more important than reported in the study of Janssen
In this context, sarcopenia is also associated with greater [46]. This study is currently unique and, until now, no re-
risk of hospitalization [37] and is highly prevalent among liable economic assessment of sarcopenia has been per-
older adults admitted to acute care wards [38] or in nurs- formed in Europe.
ing homes [39]. Sarcopenia is also a predictor of bad out- Despite this lack of other economical assessment, sev-
comes in patients who undergo major general or vascular eral studies have however looked at the relationship be-
surgery [40] or with serious illness, such as in transplant- tween sarcopenia and different area of expenditure such
ation or cancer outcome [41,42]. All these health-related as hospitalization or nursing home admission. In the
consequences of sarcopenia are supposed to alter quality United kingdom, one study has shown that, in comparison
of life in these patients [43]. with patients without sarcopenia, those diagnosed with
Importantly, several studies indicate that sarcopenia sarcopenia presented a mean length stay in hospital sig-
and indicators of alterations of muscle strength (such as nificantly higher (mean of 13.4 ± 8.8 days for sarcopenic
grip strength, walking speed, chair rises, or standing bal- subjects versus 9.4 ± 7 days for non-sarcopenic subjects;
ance) predict future mortality in middle-aged and older p = 0.003) [50]. The association between sarcopenia and
adults [21,44]. Sarcopenia is also associated with short- hospitalization was examined in another study [37] show-
and long-term mortality in hospitalized patients [38], or ing a significant association between low muscle density
in nursing home elderly residents [45]. (RR 1.5, 95% CI 1.2-1.7) and grip strength (RR 1.5, 95% CI
Taken together, these data highlight how sarcopenia 1.3-1.8) with hospitalization. Lean mass was however not
may impact various public health components, at the pa- associated with risk of hospitalization.
tient level with higher rate of disabilities, loss of independ- Although some studies have shown a higher risk of
ence, bad comorbidities outcome, institutionalization or institutionalization among frail people [51-53], regarding
mortality, but also at the societal level, contributing sarcopenia specifically, no study has currently assessed
to major healthcare and dependence costs in disabled sar- the relationship between sarcopenia and nursing home
copenic elderly (Figure 1). However, none of the proposed admissions [54].
operational definitions of sarcopenia demonstrated its Sarcopenia is also associated with other healthcare
superiority to be predictive of these health-related “hard” costs area such as loss of productivity, reduced quality of
outcomes, such as fractures, falls, admission in nursing live and loss of autonomy but also with psychological
Beaudart et al. Archives of Public Health 2014, 72:45 Page 5 of 8
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Figure 1 The complex burden of sarcopenia on public health.

problems. However, these indirect costs of sarcopenia have Targeting sarcopenia: potential impact on public health
never been quantified, neither in the US, nor in Europe. Obviously there is currently no consensual operational
In their assessment of healthcare costs of sarcopenia in definition of sarcopenia. This age-related condition has
the United States, Janssen et al. [46] also examined the ef- numerous consequences in public health, illustrated with
fect that reduced prevalence of sarcopenia would have on relevant hard clinical outcomes such as falls, fractures,
healthcare expenditure, through for example pharmaco- hospitalisations, institutionalizations, mortality. These
logical treatment, public health campaigns, physical activ- consequences directly induce high personal, social and
ity intervention,. They found that a 10% reduction in the health care systems costs, which will most certainly in-
prevalence of sarcopenia would result in saving $1.1 per crease steadily with population ageing. The implementation
year in the US. In a public health context, this potential of effective and broadly applicable preventive interventions
economic saving is important. In comparison with osteo- has become a medical and societal challenge for the grow-
porotic fractures, for which the economic costs are similar ing number of older persons affected by sarcopenia and its
[55] and for which numerous public health campaigns are disabling complications. Identifying and targeting the de-
organized aiming at reducing their occurrence, it is start- terminants of sarcopenia is a necessary first step to limit
ling to note that, for sarcopenia, no public health cam- its impact on public health (Figure 1). In addition to the
paigns are directly aimed at reducing the prevalence of identification of the determinants of skeletal muscle loss,
this important geriatric syndrome. Because the number of research strategies will have to include a lifecourse ap-
older people is increasing all over the world, health policy proach focused on factors associated with peak muscle
decision-makers should consider some money investment mass and strength, such as birth weight [56] and early nu-
in sarcopenia prevention and treatment to ensure import- trition [57]. Nutritional interventions may influence sarco-
ant future savings. penia, in particular diets rich in proteins and antioxidant
Beaudart et al. Archives of Public Health 2014, 72:45 Page 6 of 8
[Link]

nutrients, as well as vitamin D or omega-3 fatty acids sup- Competing interests

plements. Various exercise-related interventions (resistance The authors declare that they have no competing interests.

exercise training, gait, balance, coordination and func-

Authors’ contribution
tional exercises) have been tested, targeting muscle OB, JYR and RR conceived the study. CB and EB drafted the manuscript and
strength, physical function, the risk of falls and balance OB helped to draft the manuscript. All authors read and approved the final
in older people [58]. Potent pharmaceutical therapies have manuscript.

been proposed, such as hormone therapies (growth hor- Author details

mone, testosterone, selective androgen receptor modulator 1
Department of Public Health, Epidemiology and Health Economics,
dehydroepiandrosterone, estrogen), angiotensin converting University of Liège, Avenue de l’Hôpital 3 – CHU B23, Liège 4000, Belgium.
2
Support Unit in Epidemiology and Biostatistics, University of Liège, Liège,
enzyme inhibitors, ghrelin agonists, but with up to now, Belgium. 3Division of Bone Diseases, Geneva University Hospitals and Faculty
little convincing effects or with presenting adverse side of Medicine, Rue Gabrielle Perret-Gentil 4, Geneva 14 CH-1211, Switzerland.
4
effects [58]. One of the most promising approaches may Bone, Cartilage and Muscle Metabolism Unit and Chair of the Department
of Public Health Sciences, CHU of Liège, Quai Godefroid Kurth 45, Liège
be the inhibition of myostatin, a regulator of muscle develop- 4000, Belgium. 5Department of Motricity Sciences, University of Liège, Liège,
ment and growth [59,60]. It is likely that combining lifestyle, Belgium.
nutritional, pharmacological and physical interventions is
Received: 28 July 2014 Accepted: 15 October 2014
the most promising strategy. Clinical trials are currently Published: 18 December 2014
conducted in this direction, such as the DoHealth study,
which combines vitamin D, omega-3 fatty acids and References
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doi:10.1186/2049-3258-72-45
Cite this article as: Beaudart et al.: Sarcopenia: burden and challenges
for public health. Archives of Public Health 2014 72:45.

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