J Nutr Health Aging.

2020;24(1):83-90
© Serdi and Springer-Verlag International SAS, part of Springer Nature

DIFFERENCES IN THE PREVALENCE OF SARCOPENIA IN COMMUNITY-

DWELLING, NURSING HOME AND HOSPITALIZED INDIVIDUALS.
A SYSTEMATIC REVIEW AND META-ANALYSIS.
S.K. PAPADOPOULOU1, P. TSINTAVIS1, P. POTSAKI1, D. PAPANDREOU2
1. Dpt of Nutritional Sciences and Dietetics, International Hellenic University, Thessaloniki, Greece; 2. Department of Health Sciences, CNHS, Zayed University, AbuDhabi, United Arab
Emirates. Corresponding author: Dimitrios Papandreou, PhD, M.Ed, MS, RDN, Professor of Nutrition and Dietetics Department of Health Sciences, CNHS, Abu Dhabi, UAE,
Email: [email protected]

Abstract: Background: Sarcopenia is an age-related disease which leads to a decline in muscle mass and
function and is one of the most important health issues in elderly people with a high rate and variety of adverse
outcomes. Objective: The current systematic review and meta-analysis study was carried out to estimate the
overall prevalence of sarcopenia in both males and females in different regions around the world and to show
the major differences in its occurrence among different populations. Design: A systematic review and meta-
analysis of studies published in PubMed (Medline) and Scopus. Participants: Community dwelling, nursing
home and hospitalized older adults aged over 60 years. Measurements: Sarcopenia was defined by the major
validated diagnostic criteria, such as the European Working Group on Sarcopenia in Older People (EWGSOP),
the Asian Working Group for Sarcopenia (AWGS) and the International Working Group on Sarcopenia (IWGS).
The model used was the random effect model for estimating the prevalence of sarcopenia. The sex-specific
prevalence of sarcopenia as well as 95% CI (Confidence interval) were calculated using MetaXL (version 5.3).
Heterogeneity assessment was carried out by subgroup analysis. Results: We included 41 studies with a total of
34955 participants. The prevalence of sarcopenia in community-dwelling individuals in the included studies were
11% (95% CI: 8-13%) in men and 9% (95% CI: 7-11%) in women. The prevalence of sarcopenia in nursing-
home individuals in the included studies were 51% (95% CI: 37-66%) in men and 31% (95% CI: 22-42%) in
women and in hospitalized individuals were 23% (95%, CI: 15-30%) in men and 24% (95% CI: 14-35%) in
women. Conclusions: Despite the differences encountered between the studies, regarding diagnostic tools used to
measure of muscle mass, different regions around the world and different populations and clinical settings, this
systematic review revealed that a significant proportion of old people has sarcopenia (major in nursing homes),
even in populations healthy in general. However, sarcopenia is caused by the aging progress, early diagnosis
and individualized care, including physical activity and nutrition, can prevent some adverse outcomes in all
populations.

Key words: Sarcopenia, nursing home, elderly, reduced muscle mass.

Background (IWGS) published a consensus similar to that of the EWGSOP

(3). The American Foundation for the National Institutes of
Sarcopenia is a geriatric syndrome associated with ageing Health (FNIH) Sarcopenia Project published their official
that is characterized by a loss of muscle function and a consensus in 2014 (4). As a result of differences in ethnicity,
progressive loss of skeletal muscle mass. It is known to increase genetic background, and body size, the EWGSOP and IWGS
the risk of disability, falls and fall-related injuries, loss of criteria might not apply to Asians (5); therefore, sarcopenia
independence, hospitalization, and mortality (1). Characteristics experts and scientists from Taiwan, Japan, Hong Kong, South
of the population in study (such as age, sex, race and body Korea, China, Malaysia, and Thailand established the Asian
composition differences in ethnic groups), living situation Working Group for Sarcopenia (AWGS), which published
(hospitalized, community-dwelling and living in nursing guidelines for diagnosing sarcopenia in 2014 (6).
homes) and the used methodology to assess sarcopenia’s It is worth mentioning that in early 2018, the Working Group
parameters cause a significant variation in the rate of this met again (EWGSOP2) to update the original definition in
disease. order to reflect scientific and clinical evidence that has built
In order to improve the early recognition, diagnosis, and over the last decade. The new consensus (1) focuses on low
management of sarcopenia, as well as to stimulate further muscle strength as a key characteristic of sarcopenia, uses
research, there have been published several guidelines. In 2010, detection of low muscle quantity and quality to confirm the
the European Working Group on Sarcopenia in Older People sarcopenia diagnosis, and identifies poor physical performance
(EWGSOP) introduced the first and most popular consensus, as indicative of severe sarcopenia; (2) updates the clinical
which suggested cut-offs of muscle mass, muscle strength, and algorithm that can be used for sarcopenia case-finding,
physical performance for assessing and diagnosing sarcopenia diagnosis and confirmation, and severity determination and (3)
(2). In 2011, the International Working Group on Sarcopenia provides clear cut-off points for measurements of variables that
Published online October 3, 2019, http://dx.doi.org/10.1007/s12603-019-1267-x
Received July 13, 2019
Accepted for publication August 8, 2019 83
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identify and characterize sarcopenia (3). prevalence of sarcopenia, results and conclusions. Another
Because of the different measurement tools, cutoff points reviewer verified the extracted information.
and sarcopenia criteria, prevalence results may be difficult to
interpret. In addition, the major differences in the prevalence of Statistical Analysis
sarcopenia according to the population (community dwelling, The pooled prevalence of sarcopenia with 95% confidence
hospitalized and living in nursing homes), makes it more intervals (CIs) was estimated using a random effects model.
difficult to establish preventative routines and therapeutic Heterogeneity was assessed by subgroup analysis. Severe
protocols and it requires a more personalized approach. heterogeneity was indicated as the heterogeneity of studies
This meta-analysis aims to show the variations in the was greater than 50%. Publication bias was assessed using
prevalence of sarcopenia in adults aged 60 years according Doi plots. All meta-analysis methods were performed using
to different populations (community-dwelling, hospital, MetaXL 5.3.
nurse homes) and to provide awareness of such a serious,
multifactorial and often undiagnosed disorder (3). Results

Methods The literature searches yielded 2102 studies (including 32

duplicates). According to inclusion criteria, we assessed titles
The pre-defined review protocol was registered and abstracts and 108 studies were selected. After reviewing
prospectively with the International Prospective Register of full texts, 41 studies were suitable for the meta-analysis (Figure
Systematic Reviews (PROSPERO—registration number: 1).
CRD42019130570).
Figure 1
Search Strategy PRISMA diagram for study selection
The search was carried out in the electronic database of
PubMed (Medline) and Scopus between January 2009 and
January 2019. The pre-defined search terms were: “sarcopenia”
and “prevalence” or “frequency” or “incidence” or “muscle
strength” or “muscle mass” or “muscle wasting”. The list of
references of articles was also reviewed for any additional
papers. Search was not limited by language.

Inclusion and Exclusion Criteria

We included only studies that had enrolled participants
aged 60 years and older within well-defined populations (such
as those in community-dwelling, hospital and nursing home/
geriatric settings). We included studies that prevalence of
sarcopenia had been assessed according to the EWGSOP,
AWGS or IWGS definitions of sarcopenia, i.e. based on muscle
mass (adjusted appendicular muscle mass for height) and
muscle strength (handgrip strength) or physical performance
(the usual gait speed). We excluded studies that focused on
patients with diseases, such as cancer patients and hemodialysis
patients.
Research papers were selected based on titles and abstracts.
The full texts of all chosen publications were assessed
for pertinence. The process initially performed by two
investigators. A third investigator adjudicated discrepancies
between the two reviewers.
A total of 34955 individuals, 15599 (45%) men and 19347
Data Extraction (55%) women; respectively, from the general population
Two reviewers extracted the information from all studies were examined through these studies. 30287 individuals were
included using an excel form that we developed using a community-dwelling individuals, whereas 3802 and 886
modified STROBE checklist. The following information was individuals were from hospitals and nursing homes accordingly.
included: study design and methods, country, number of study Thirteen studies were distributed in Asia and there were also
settings, diagnostic criteria of sarcopenia, study outcomes, the 28 studies from non-Asian countries, 21 of them being from

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Europe. A total of 15 studies used the Dual Energy X-Ray equaled 0.93 (no asymmetry) in men and 0.00 (no asymmetry)
Absorptiometry (DXA) to assess muscle mass, 21 studies used in women, there is no publication bias being identified.
the Bio-electrical Impedance Analysis (BIA) and 6 studies used
anthropometric equations. In a study both DXA and BIA were Figure 3
used to assess muscle mass (7). The PRISMA diagram for study Forest plot on the prevalence of sarcopenia in community-
selection is shown in Figure 1. dwelling Women – total and divided in three subgroups (Asian,
non-Asian and European)
Figure 2
Forest plot on the prevalence of sarcopenia in community-
dwelling Men – total and divided in three subgroups (Asian,
non-Asian and European)

Subgroup Analysis

Muscle mass assessment methods

Meta-analysis According to the muscle mass assessment method (DXA,
The overall prevalence of sarcopenia in the included studies BIA and anthropometrics), the prevalence of sarcopenia in
were 14% (95% CI: 11-17%) in men and 12% (95% CI: community dwelling men was 11%, 9% and 9% accordingly
10-15%) in women. Substantial heterogeneity observed in and in women was 8%, 10% and 13%.
men (Q=1186.45, p=0.00, I2=96%) and women (Q=1188.18,
p=0.00, I2=96%). Countries
Because of the major differences in the prevalence of Community dwelling individuals living in non-Asian
sarcopenia among community-dwelling individuals (10% countries were found more likely to be sarcopenic than those
prevalence), nursing-home individuals (38% prevalence) living in Asian countries. This was true among both genders
and hospitalized individuals (23% prevalence) as shown in (13% vs 9% in men, 11% vs 8% in women). The prevalence of
figure 6, we examined these populations separately analyzing sarcopenia in Europe was 13% for men and 14% for women.
extensively only the community-dwelling group.
Criteria
Community Dwelling individuals There is a small difference in the prevalence of sarcopenia in
The prevalence of sarcopenia in community dwelling community dwelling men and women according to the criteria
individuals in the included studies were 11% (95% CI: 8-13%) used. In community dwelling men the prevalence ranges from
in men and 9% (95% CI: 7-11%) in women. Substantial 11%, 12% and 8% using EWGSOP, AWGS and IWGS criteria
heterogeneity observed in men (Q= 770.68, p=0.00, I2=95%) accordingly and in women ranges from 10%, 11% and 5%
and women (Q= 652.35, p=0.00, I2=94%). using EWGSOP, AWGS and IWGS criteria accordingly.
According to the Doi plot and the value of the LFK index

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Nursing home/hospitalized individuals Figure 6

The prevalence of sarcopenia in nursing-home individuals Forest plot on the prevalence of sarcopenia divided in
in the included studies were 51% (95% CI: 37-66%) in men subgroups by population. The prevalence of sarcopenia in
and 31% (95% CI: 22-42%) in women and in hospitalized community-dwelling individuals is 10%, in nursing-home
individuals were 23% (95%, CI: 15-30%) in men and 24% individuals is 38% and in hospitalized individuals is 23%
(95% CI: 14-35%) in women.

Figure 4
Forest plot on the prevalence of sarcopenia in community-
dwelling Men divided in subgroups by criteria (EWGSOP,
AWGS, IWGS)

Figure 5
Forest plot on the prevalence of sarcopenia in community-
dwelling Women divided in subgroups by criteria (EWGSOP, Discussion
AWGS, IWGS)
Sarcopenia is considered to be an independent risk factor
for various adverse outcomes, including difficulties in basic
and instrumental ADL, osteoporosis, falls, length of stay at the
hospital and re-admission as well as death (46).
The prevalence of sarcopenia in the literature varies
widely and is likely to be affected by the population studied
(community-dwelling, nursing homes and hospitals), the criteria
used (EWGSOP, AWGS, IWGS) and the different methods
utilized to assess muscle mass, muscle strength and physical
performance.
In our study we found that in non-Asian countries, the
prevalence of sarcopenia was more likely than in the Asian
community dwelling individuals (13% vs 9% in men, 11% vs
8% in women). These results can be attributed to various factors
such as racial characteristics, body size, cultural background,
dietary regimes, and life quality of the elderly between the
Asian and non-Asian individuals in different countries. Also,
the cut-off points for the Asian populations are lower than for
the non-Asian individuals in both genders, with young people
of the same ethnic group as reference (47).

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Table 1
Characteristics of studies included in this meta-analysis

Studies Region Population Sample (N) Total- Criteria Assessment method for muscle Total N Male N Female N
Male-Female mass
Rossi A et al.2017 (8) Italy Community-dwelling 274-97-177 EWGSOP DXA 92 28 64
Wang H et al. 2018 (9) China Community-dwelling 865-427-438 AWGS BIA 61 28 33
Silva Neto L et al. 2016 (10) Brazil Community-dwelling 70-31-39 EWGSOP DXA 7 5 2
Hai S et al. 2017 (11) China Community-dwelling 834-415-419 AWGS BIA 88 47 41
Hu X et al. 2017 (12) China Community-dwelling 607-251-356 AWGS Anthropometric equation ASM 112 41 71
Bahat G et al. 2018 (13) Turkey Community-dwelling 207-67-140 BIA
1 EWGSOP 8 7 1
2 FNIH 19 6 13
3 IWGS 4 3 1
4 SCWD 4 4 1
Lee W et al. 2013 (5) Taiwan Community-dwelling 386-223-163 DXA
1 IWGS 16 13 3
2 EWGSOP 30 24 6
3 IWGS 43 24 19
4 EWGSOP 63 33 31
Wen X et al. 20151 (4) China Community-dwelling 286-136-150 Anthropometric equation ASM
1 IWGS 17 10 7
2 AWGS 9 8 1
3 EWGSOP 1 1 0
Clynes M et al. 20151 (5) UK Community-dwelling 298-156-142 DXA
1 Community-dwelling EWGSOP 10 7 3
2 Community-dwelling IWGS 25 13 12
Wang H et al. 2016 (7) China Community-dwelling 636-316-320 AWGS DXA and BIA 66 26 40
Akune T et al. 2014 (16) Japan Community-dwelling 1000-349-651 EWGSOP BIA 129 48 81
Yoo J et al. 2017 (17) Korea Community-dwelling 4020-1698-2322 AWGS DXA 759 508 251
Yu R et al. 2014 (18) China Community-dwelling 4000-2000-2000 EWGSOP DXA 216 109 107
Dodds R et al. 2017 (19) UK Community-dwelling 719-282-437 EWGSOP BIA 149 59 90
Yang M et al. 2018 (20) China Community-dwelling 384-160-224 AWGS BIA 61 19 42
Lera L et al. 2017 (21) Chile Community-dwelling 1006-319-687 EWGSOP DXA 192 62 130
Gao L et al. 2015 (22) China Community-dwelling 612-254-358 AWGS Anthropometric measures 60 17 43
Patel H et al. 2013 (23) UK Community-dwelling 1787-765-1022 EWGSOP FFM 116 35 81
Bahat G et al. 2018 (24) Turkey Community-dwelling 242-77-165 EWGSOP BIA 2 1 1
Ohara D et al. 2018 (25) Brazil Community-dwelling 383-132-251 EWGSOP Equation TMM 48 14 34
Beaudart C et al. 2015 (26) Belgium Community-dwelling 534-212-322 EWGSOP DXA 73 25 48
Yoshida D et al. 2014 (27) Japan Community-dwelling 4811-2343-2468 EWGSOP BIA 360 192 168
Legrand D et al. 2013 (28) Belgium Community-dwelling 288-103-185 EWGSOP BIA 36 13 23
Zengin A et al. 2018 (29) Gambia Community-dwelling 486-238-248 EWGSOP DXA 59 37 22
Bianchi L et al. 2016 (30) Italy Community-dwelling 538-250-288 EWGSOP BIA 55 19 36
Beaudart C et al. 2014 (31) Belgium Community-dwelling 400-157-243 EWGSOP DXA
1 61 23 38
2 72 23 49
Hashemi R et al. 2016 (32) Iran Community-dwelling 300-146-154 EWGSOP DXA 54 30 24
Villada F et al. 2015 (33) Spain Community-dwelling 258-83-175 EWGSOP DXA 6 4 2
Phillips A et al. 2017 (34) Germany Community-dwelling 927-473-454 EWGSOP BIA 53 19 34
Christensen M et al. 2018 (35) Denmark Community-dwelling 80-28-52 EWGSOP DXA 21 8 13
Yoo J et al. 2016 (36) Korea Hospitalized 1614-664-950 AWGS DXA 174 107 67

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Table 1 (continued)
Characteristics of studies included in this meta-analysis

Studies Region Population Sample (N) Total- Criteria Assessment method for muscle Total N Male N Female N
Male-Female mass
Rossi A et al. 2014 (37) Italy Hospitalized 119-78-41 EWGSOP BIA 31 13 18
Bianchi L et al. 2017 (38) Italy Hospitalized 655-315-340 EWGSOP BIA 227 115 112
Smoliner C et al. 2014 (39) Germany Hospitalized 198-59-139 EWGSOP BIA 50 20 30
Buckinx Fanny et al. 2017 (40) Belgium Nursing home 662-182-480 EWGSOP BIA 252 78 174
Senior H et al. 201 (51) Australia Nursing home 102-31-71 EWGSOP BIA 41 15 26
Landi F et al. 2012 (41) Italy Nursing home 122-31-91 EWGSOP BIA 40 21 19
Jacobsen E et al. 2016 (42) Norway Hospitalized 120-44-76 EWGSOP anthropometric measures MAMC 36 3 33
Sousa A et al. 2015 (43) Portugal Hospitalized 193-112-81 BIA
1 EWGSOP 69 38 31
2 EWGSOP 72 46 26
3 EWGSOP 14 10 4
Martone A et al. 2017 (44) Italy Hospitalized 394-183-211 EWGSOP BIA 58 29 29
Cerri A et al 2015 (45) Italy Hospitalized 103-42-61 EWGSOP BIA 22 10 12

Most of the studies we included used the Bio-electrical ones that are hospitalized (23% incidence of sarcopenia) and the
Impedance Analysis (BIA, 21 studies) to asses muscle mass, least prevalent individuals who are community-dwelling (10%
followed by the Dual Energy X-Ray Absorptiometry (DXA, incidence of sarcopenia). One systematic review and meta-
15 studies) and anthropometric equations (6 studies). The analysis done in 2018 found that the prevalence of sarcopenia
prevalence of sarcopenia varies according to the tool used to in nursing homes is 41% (52), which is close to our results
measure muscle mass. BIA is known to underestimate fat mass of 38%. Another meta-analysis done in 2017 found that the
and overestimate muscle mass (49). Previous studies found prevalence of sarcopenia in community dwelling individuals is
that the BIA-based prevalence of sarcopenia was higher than 10%(47) which completely agrees with our results of 10%.
the DXA- based approach (50, 51). In our study we found
that according to the muscle mass assessment method (DXA, Physical activity and nutrition
BIA and anthropometrics), the prevalence of sarcopenia in A lot of studies state that higher physical activity levels
community dwelling men was 11%, 9% and 9% accordingly are associated with lower sarcopenic risk (18). The physical
and in women was 8%, 10% and 13%. activity and the nutritional status are some of the major factors
The overall pooled prevalence of sarcopenia among that we found such a difference in the prevalence of sarcopenia
all populations in the included studies was higher in men in nursing homes and hospitalized patients (38% and 23%),
(14%) and lower in women (12%). Epidemiological data for who spend a lot of hours in bed and often do not have a choice
discordance in sarcopenia prevalence between older men and of what foods to eat, in comparison to community dwelling
women have been conflicting. Several studies had suggested individuals (10%) that are more physically active and choose
differential sex-specific rate of absolute muscle loss, being their own foods.
greater in men than in women, which could not be attributed Sarcopenic individuals in nursing homes reported more
merely to the larger initial muscle mass in men by interleukin-6 sitting time, were less likely to report being currently physical
(IL-6) in women (48). active and also were more likely to be malnourished (1, 40, 41).
It is worth mentioning that we found a lower incidence of Hospitalized individuals might represent an additional risk
sarcopenia in the studies used the IWGS criteria in comparison factor for sarcopenia and functional decline because of reduced
with the EWGOP-based and AWGS-based studies. This caloric intake, low physical activity or prolonged bed-rest,
was not surprising because EWGSOP and AWGS classify depressed mood, and social isolation (38, 44).
sarcopenia as low muscle strength with low muscle mass Community-dwelling individuals are more likely to be
without low physical performance as IWGS does (5). sarcopenic if they are less physically active and don’t have a
Our review is the first systematic review and meta-analysis good nutritional status (7, 11, 12, 18, 22).
to compare the differences in the prevalence of sarcopenia It is also worth mentioning that sarcopenia may be less
among different populations (community-dwelling, prevalent in Asian populations due to differences in lifestyle.
hospitalized, nursing home). Based on our findings, the most These differences include better dietary aspect and higher levels
prevalent individuals to sarcopenia are the ones who live in of activity than the Western populations, which act as protective
nursing homes (38% incidence of sarcopenia) followed by the factors against sarcopenia (47).

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Our review revealed that the currently available studies 2017;17(1):187. doi:10.1186/s12877-017-0587-0
12. Hu X, Jiang J, Wang H, Zhang L, Dong B, Yang M. Association between sleep
addressing sarcopenia in nursing homes and hospitals were duration and sarcopenia among community-dwelling older adults. Med (United
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addressing community-dwelling individuals. Hence, there seem 13. Bahat G, Oren MM, Yilmaz O, Kiliç C, Aydin K, Karan MA. Comparing SARC-F
with SARC-CalF to Screen Sarcopenia in Community Living Older Adults. J Nutr
to be significant opportunities to expand our understanding Heal Aging. 2018;22(9):1-5. doi:10.1007/s12603-018-1072-y
of sarcopenia by carrying out further well-designed and well- 14. Wen X, An P, Chen WC, Lv Y, Fu Q. Comparisons of sarcopenia prevalence
reported studies to compare the various diagnostic criteria based on different diagnostic criteria in Chinese older adults. J Nutr Heal Aging.
2015;19(3):342-347. doi:10.1007/s12603-014-0561-x
of sarcopenia on different populations for the prediction of 15. Clynes MA, Edwards MH, Buehring B, Dennison EM, Binkley N, Cooper C.
death and other clinical outcomes (such as quality of life and Definitions of Sarcopenia: Associations with Previous Falls and Fracture in a
hospitalization). It is also interesting to evaluate the use of Population Sample. Calcif Tissue Int. 2015;97(5):445-452. doi:10.1007/s00223-015-
0044-z
targeted nutrition, nutritional supplements and exercise regimes 16. Akune T, Muraki S, Oka H, et al. Exercise habits during middle age are associated
on the outcomes of sarcopenia in nursing homes and hospitals. with lower prevalence of sarcopenia: The ROAD study. Osteoporos Int.
2014;25(3):1081-1088. doi:10.1007/s00198-013-2550-z
17. Yoo J Il, Ha YC, Lee YK, Hana-Choi, Yoo MJ, Koo KH. High prevalence of
Conclusion sarcopenia among binge drinking elderly women: a nationwide population-based
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community-dwelling individuals. Low physical activity and 2014;14(SUPPL.1):15-28. doi:10.1111/ggi.12220
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Conflict of Interest: None for all authors doi:10.14283/jfa.2016.117
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