The Diagnosis and Treatment of Sarcopenia and Sarcopenic Obesity

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.

Cite this as: Habboub B, Speer R, Gosch M, Singler K: The diagnosis and treatment of sarcopenia and sarcopenic obesity. Dtsch Arztebl Int 2025; 122: 121–6. DOI: 10.3238/arztebl.m2025.0004

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, 3, 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, 12, 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

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

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

eBox

Diagnostic work-up: an example

eFigure

Diagnostic algorithm for sarcopenia according to EWGSOP2

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.

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

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, 12, 13, 30).

Table 3

Treatment recommendations for sarcopenia and sarcopenic obesity

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, 12, 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)

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

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, 12, 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, 12, 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.

Conflict of interest statement
BH received travel grants from the DGG and the Paracelsus Medizinische
Privatuniversität Nürnberg, Germany.

MG is President of the German Geriatrics Society (Deutsche Gesellschaft für Geriatrie).

RS has an employment relationship with Danone Deutschland GmbH.

The remaining authors declare that no conflict of interest exists.

Manuscript submitted on 30 July 2024, revised version accepted 8 January 2025.

Translated from the original German by Christine Rye.

Corresponding author
Basel Habboub

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