Regional Differences in the Diagnosis of Sarcopenia in Older People in Brazil

Research Article

Gerontol Geriatr Res. 2021; 7(4): 1063.

Regional Differences in the Diagnosis of Sarcopenia in Older People in Brazil

Menezes JM¹, Paes AT² and Frisoli-Junior A³*

1Faculdade Israelita de Ciências da Saúde Albert Einstein, Brazil

2Instituto Israelita de Ensino e Pesquisa Albert Einstein, Brazil

3Department of Cardio Geriatrics, Universidade Federal de São Paulo, Brazil

*Corresponding author: Frisoli-Junior A, Department of Cardio Geriatrics, Escola Paulista de Medicina, Universidade Federal de São Paulo, 715 Napoleão de Barros Street, São Paulo, Brazil

Received: August 20, 2021; Accepted: September 20, 2021; Published: September 27, 2021


Introduction: Sarcopenia is a prevalent condition, and that is strongly associated with morbimortality outcomes. The optimal way to diagnose sarcopenia is currently a matter of debate. Despite evidence suggesting differences in body composition and physical performance of individuals from different regions, the diagnosis of sarcopenia in Brazil is still conducted using cutoff values established by international consensus. Therefore, the objective of this study was to establish cutoff values for appendicular muscle mass and muscle strength in a population of elderly outpatients with cardiovascular diseases from the city of São Paulo, using this data to compare populations with sarcopenia diagnosed in Brazil with individuals diagnosed using the European consensus values.

Materials and Methods: This was a cross-sectional analysis including 502 older individuals from the SARCOS-Brazil study. All subjects underwent densitometry to assess muscle mass and measure strength using a manual dynamometer. The cutoff values for the SARCOS-Brazil criteria were obtained from the 25th percentile of each variable.

Results and Discussion: There was no difference in the prevalence of muscle weakness using the two methods (180 patients, 35.9% of the sample). However, a difference was observed concerning low muscle mass. According to the European criteria, a total of 215 older individuals (42.8%) had low muscle mass and 123 (24.5%) according to the SARCOS-Brazil criteria. The prevalence of sarcopenia was 20.3% according to European criteria versus 13.7% according to the SARCOS-Brazil criteria. The kappa coefficient was 0.79.

Conclusion: This study suggests that weakness and muscle mass can, in isolation, predict variables related to past vulnerability outcomes, as well as highlights the possibility of using regional cutoff values for the diagnosis of sarcopenia.

Keywords: Sarcopenia; Aging; Muscle mass; Muscle strength


CVA: Cerebrovascular Accident; DM: Diabetes Mellitus; DLP: Dyslipidemia; COPD: Chronic Obstructive Pulmonary Disease; CKD: Non-Dialytic Chronic Kidney Disease; DXA: X-Ray Dual Emission Densitometry; SAH: Systemic Arterial Hypertension; CHF: Congestive Heart Failure; IMC: Body Mass Index; MEEM: Mini- Mental Status Examination; ASFFM Appendicular Skeletal Fat-Free Mass


Sarcopenia is defined as a decrease of physical ability associated with loss of muscle mass due to aging. The prevalence varies according to country, ethnicity, diagnostic criteria, and population (community, hospital environment, or permanent residency). The incidence ranges between 2.5 to 27.2% in women and 3.1 to 20.4% in men older than 65 [1]. In Brazil, it is estimated that 17% of people older than 60 years are sarcopenic [2].

The importance of sarcopenia is related to the risk of fractures and falls [3-5] and the development of cardiovascular diseases [6,7] frailty [8], reduction in the quality of life [9], increasing hospitalization [10], and death [11-13]. However, the diversity of the diagnostic criteria and cutoff values adopted for low muscle mass and weakness have limited the standardization of universal criteria for sarcopenia and reduced the adoption of preventive policies against the progression of unwanted outcomes.

The differences among diagnostic methods have generated a growing instability in determining those variables and values that would be more appropriate for sex, age range, ethnicity, and country of origin. The European Working Group on Sarcopenia in Older People - EWGSOP II [14] suggested muscular mass and physical performance measures to identify sarcopenia. The American Group Foundation for the National Institutes of Health – FNIH [15] indicated that physical performance measures only would be sufficient to describe individuals with physical vulnerability. Nevertheless, there is a significant difference between values of cutoff adopted for these criteria according to sex, ethnicity [16,17], and country of origin [18- 20].

Significant differences in body composition and physical performance have been shown in terms of ethnicity. A cross-sectional study conducted in 2012 in Boston, USA, found that Hispanic people present on average lower muscle mass than White and Black people, in addition to low grip strength [21]. Despite this evidence, international consensus determining cutoff values are based on regional population studies stratified by sex, and there is no stratification by ethnicity.

This issue related to cutoff values is even more relevant in Brazil. This is because there are significant numbers of individuals of African descent and other ethnic groups and varied eating habits, physical exercise practices, sun exposure, and smoking, among others, that may modulate the quality of muscle mass [22]. Despite this heterogeneity, there are no data on muscle mass and physical performance in Brazilians that can be used to diagnose sarcopenia. This situation limits the understanding of related outcomes, given that the values used are based on criteria for American and European populations.


The objective of this study was to evaluate cutoff values for appendicular muscle mass and strength in an older outpatient population with cardiovascular diseases from the city of São Paulo, SP (SARCOS-Brazil criteria) and to investigate whether low muscle mass, muscle weakness and sarcopenia, either by the European consensus (EWGSOP II) or by SARCOS-Brazil, were associated with past vulnerability variables.

Materials and Methods


This was a cross-sectional analysis of the Sarcopenia and Osteoporosis Study in Older Individuals with Cardiovascular Diseases (SARCOS), a prospective study concerning the association of sarcopenia and osteoporosis as a common pathway for functional loss and weakness among ambulatory elderly patients.


The sample included 502 older adults of both sexes and any ethnicity among outpatients from the cardiogeriatrics department of the Federal University of São Paulo, SP, Brazil. Exclusion criteria were nationality other than Brazilian, unstable medical conditions, any type of cancer within the previous five years, chronic renal failure requiring dialysis, Parkinson’s disease, any severe infectious disease requiring hospitalization in the previous month, moderate or severe dementia according to the Mini-Mental Status Examination, and the use of an auxiliary gait device.

After providing informed written consent, individuals underwent a physical examination, physical performance test, bone density measurement, and total body test. The Ethical and Research Committee of the institution where the study was conducted provided approval (CEP/UNIFESP n°682659).

Variables of interest

Demographic characteristics: We evaluated the following demographic characteristics: age, sex, marital status (single, married, separated, divorced, widow or widower), personal income, body mass index (BMI), and ethnicity. The characterization of ethnicity was selfidentified as White, Black, or Asian.

Cardiovascular and chronic diseases: We evaluated the following cardiovascular diseases: Systemic Arterial Hypertension (SAH), Diabetes Mellitus (DM), Congestive Heart Failure (CHF), previous Cerebral Vascular Accident (CVA) (more than 6 months prior), and Dyslipidemia (DLP). We considered the following chronic diseases: Chronic Kidney Disease (CKD) not requiring dialysis, Chronic Obstructive Pulmonary Disease (COPD), and past cancer history. All information on diseases was obtained from medical records.

Lifestyle: At the outset of the study, we gathered information on lifestyle in terms of current or former smoking habits, total cigarette packs per year, and current or former consumption of alcohol.

Measures of body composition: All subjects underwent dualenergy x-ray absorptiometry (DXA) (GE Lunar; DPX-MD 73477, GE Medical Systems, Madison, WI, EUA) to measure parameters of total body composition and regional muscle mass (left arm and leg, right and left arm, and trunk) in kilograms and percentage. The appendicular skeletal muscle mass was obtained by summing the muscle mass of arms and legs (kilograms) divided by squared height (m), resulting in Appendicular Skeletal Fat-Free Mass (ASFFM). The BMI was calculated as weight (kilograms) divided by the squared height (m). The total body fat percentage was calculated as the sum of the fat of arms, legs, trunk, and pelvis. In our laboratory, in vivo precision (variation coefficient, CV%) was based on repetitive screening of ten individuals with repositioning of 1.3% for fat mass and 0.8% for fat-free mass.

Strength measures: Strength pressure of the upper limb was measured using a manual dynamometer (Jamar; TEC; Clifton, NJ, USA) determined by three consecutive measures and recording considered maximum value.

Sarcopenia diagnosis:

Sarcopenia according to the European criteria: Sarcopenia was diagnosed according to the recommendation of EWGSOP II (14), in which individuals with pressure strength equivalent or inferior to 27 kilograms for men and 16 kilograms for women and ASFFM < 7.0 kilograms/m2 for men and < 6.0 kilograms/m2 for women were considered sarcopenic. In this situation, cutoff values are the same for all ethnicities, according to the consensus opinion.

Sarcopenia according to the 25th percentile of the sample: We determined parameters of ASFFM and muscular strength for the Brazilian population with percentiles 25 of the sample for each of the variables [21,23]. The flowchart for diagnosis according to SARCOSBrazil criteria followed those used by EWGSOP II, i.e., weakness associated with low ASFFM.

Variables of previous vulnerability: Patients with low muscle mass and muscular weakness and who had sarcopenia according to one of the criteria (SARCOS-Brazil and EWGSOP II) were analyzed concerning two variables of previous vulnerability: falls and hospitalizations.

Statistical analysis

Clinical features were expressed as total numbers and percentages for qualitative variables. We included standard deviations for normally distributed quantitative data and median + interquartile interval for non-normally distributed data. The agreement between SARCOS-Brazil and EWGSOP II criteria for sarcopenia diagnosis were analyzed using contingency tables and kappa coefficient. Sarcopenic groups according to each criterion were analyzed concerning previous vulnerability using multiple logistic regression controlling for confounding variables. The variables included in multivariate models were selected based on the association found in simple logistic regression. Data analysis was performed using SPSS (22.0, Chicago, EUA).


Of 502 older adults, 277 (55.2%) were women, and the mean age was 78.4 ± 7.1 years (Table 1). Concerning ethnicity, 339 (67.5%) were White, 145 (28.9%) were Black, and 18 (3.6%) were Asian. Most participants were married (46.9%) with a mean personal income of 1.6 ± 1.5 times the minimum salary. The mean body mass index was 26.8 ± 4.6 kilograms/m2. The patients had several comorbidities, most frequently DM (40.6%), SAH (92.8%), DLP (69.7%), CHF (31.5%), COPD (9.6%), CVA (12.5%), and history cancer (13.1%).