#186 Sarcopenia: Raising the Bar in Primary Care

December 2, 2019 | By Cyrus Askin

How to Identify and Treat Patients with Low Muscle Mass, Low Muscle Strength and Reduced Physical Performance

Make some gains with Drs. Feigenbaum (@Jordan_theCoach) & Baraki (@AustinBaraki) of Barbell Medicine as we delve into the topic of sarcopenia! Together we’ll learn what exactly is sarcopenia, how it is diagnosed, and explore approaches to both management and counseling including: exercise prescriptions,  recommendations for protein intake, and even how to treat patients with multiple comorbidities.

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Credits

Written and Produced by:  Cyrus Askin MD

Infographic: Cyrus Askin MD and Hannah Abrams

Cover Art: Dr. Kate Grant MBChB DipGUMed

Hosts: Stuart Brigham MD; Matthew Watto MD, FACP; Paul Williams MD, FACP   

Editors: Matthew Watto MD, FACP; Clair Morgan of Nodderly.com

Guests: Jordan Feigenbaum MD; Austin Baraki MD

Check Out our friends at Barbell Medicine!

Learn more about Barbell Medicine through their website at www.barbellmedicine.com or their YouTube channel – Barbell Medicine. They also have their own Podcast, The Barbell Medicine Podcast and can be found on Instagram: @barbell_medicine, Twitter via @BarbellMedicine.

Drs. Feigenbaum and Baraki can be found on instagram via Jordan_BarbellMedicine & Austin_BarbellMedicine. They can also be found on Twitter via @AustinBaraki, @Jordan_theCoach.

Time Stamps

• 00:00 Intro, disclaimer, guest bio
• 03:20 Guest one-liners; Picks of the Week*: Explain Pain (book) and Explain Pain Super Charged; Range Why Generalists Triumph in a Subspecialized World (book) by David Epstein; The Sports Gene: Inside the Science of Extraordinary Athletic Performance (book); The Mind’s Eye (book) by Oliver Sacks; The Predator High Five (Gif); The Bacterionomicon
• 08:50 How Austin and Jordan got into coaching, fitness and lifestyle medicine
• 14:30 Case of chronic pain, lack of exercise and loss of muscle mass; Defining sarcopenia, cachexia, frailty
• 22:30 How to diagnose sarcopenia -measures of physical performance (Repeat Chair Sit to Stand; Timed Get Up and Go Test; Gait Speed); DXA scans; The SARC-F questionnaire; Serum Creatinine
• 33:30 Anabolic resistance; Sarcopenic obesity and Osteosarcopenic obesity
• 37:00 How to counsel patients about physical activity
• 40:00 The 10,000 step thing is based on marketing, not evidence
• 41:30 How to sell exercise to patients with comorbidities; Barriers to and safety of resistance training
• 49:39 Finding a physical trainer
• 53:18 Dietary protein intake recommendations
• 61:33 What kind of results might patients expect
• 65:55 Take home points
• 68:11 Plugs: Barbell Medicine podcast, Instagram, YouTube and Twitter
• 69:15 Outro and a pun

Sarcopenia Pearls

1. Sarcopenia: The prior definition of decreased muscle mass or “poverty of flesh” is being replaced with a syndromic one featuring low muscle mass, low muscular strength and poor physical performance
2. Cachexia & Frailty do NOT equal Sarcopenia: These terms are not synonymous with sarcopenia and imply either a complex metabolic derangement or decrease in homeostatic reserves 
3. Age > 65 and subjective complaints of weakness? Consider assessing this patient for sarcopenia
4. Focus on performance assessments to identify sarcopenia: Things like the get-up-and-go test, sit-to-stand and gait-speed can easily be incorporated in a clinician’s work-flow and provide meaningful data
5. Current Recommendations for Exercise: At least 150-300 min of moderate intensity aerobic training or 75-150 min of vigorous training (based upon METS of 4-6 vs. 6+, respectively) with resistance training at least twice weekly
6. How much Protein? 1.0-1.2 gm of protein/kg of body weight/day in older adults (>65 y/o) and 1.2-1.5 gm of protein/kg of body weight/day in those with severe illness or injuries

Sarcopenia – In-Depth Show Notes 

What is sarcopenia and why care?

• Sarcopenia: Decreased muscle mass, “poverty of flesh”
  • European Working Group on Sarcopenia in Older People (EWGSOP) – shifting emphasis of definition towards muscle strength rather than muscle mass (i.e. chronic skeletal muscle failure) (Cruz-Jentoft et al 2010, Cruz-Jentoft et al 2019)
  • “3 Prongs” of Sarcopenia
    • Low muscular strength
    • Low muscle mass
    • Poor physical performance
• Not interchangeable with cachexia or frailty
  • Cachexia: “…a complex metabolic syndrome associated with underlying illness and characterized by loss of muscle with or without loss of fat mass.” (Evans et al 2008)
  • Frailty: “a clinical state in which there is an increase in an individual’s vulnerability to developing negative health-related events (including disability, hospitalizations, institutionalizations, and death) when exposed to endogenous or exogenous stressors.” (Cesari et al 2017)
• What makes muscle-loss / strength loss pathologic?
  • Handgrip strength tends to increase until the 2nd or 3rd decade of life, declines between the 3rd and 5th decade of life, and then declines more rapidly thereafter
  • Difficult to establish clear cut offs, however, could think of an “inflection point” at which time decreased strength/muscle mass either in and of itself or in association with other disease states, contributes to morbidity
  • A clinician could consider comparing a patient suspected of sarcopenia with an age matched “control” to help make the diagnosis
  • Several disease states have been examined with an eye towards the presence of sarcopenia and the implications that may have on a patient’s “performance” (example: heart failure – Emami et al 2018) 
• Sarcopenic obesity: probably underdiagnosed (Choi 2016)
  • Osteosarcopenic Obesity – sarcopenic obesity in patients with osteoporosis – not surprising given correlation between muscle mass and obesity (Ilich et. al 2016)

When to suspect sarcopenia?

• Age > 65 – at higher risk for sarcopenia vs. younger patients
• Low BMI (Tanishima et al 2017)
• Complaint of “muscle weakness” or inability to perform activities

Making the Diagnosis

• EWGSOP: recommend a diagnostic approach, however, it’s impractical to expect providers to invest in specialized tools such as handgrip dynamometers, although this is a well-validated means to assess muscular strength (Sousa-Santos et al 2017)
• Physician performance metrics 
  • Short physical performance battery
  • 6 minute walk
  • Preferable (due to time and ease of use):
    • Repeat chair sit-to-stand (cross arms, get out of chair 5x, should take less than 15 seconds) (Alcazar et al 2018)
    • Timed up and go test (Podsiadlo et al 1991)
    • Gait speed (0.8 m/s is the cut off) (Chen et al 2014)
• DXA Scan: Can obtain skeletal muscle mass index off of a DXA (Kuriyan 2018)
  • 2 SD from the mean is a good cutoff to remember
• May have bioelectrical impedance which can be used (Kuriyan 2018)
• Calf circumference (<31cm is the cut off) (Pagotto et al 2018) 
  • Beware! –  This can be prone to errors given how older patients store muscle mass, patients with lower extremity edema
• Labs/Blood Work?
  • No lab work is recommended to make the diagnosis
  • In hospitalized populations, there are established creatinine cut-offs that can suggest low muscle mass
• SARC-F Questionnaire (Malmstrom et al 2016)
  • Five components: strength, assistance walking, rise from a chair, climb stairs, and falls
  • Total score is out of 10, with 0-2 points for each domain listed above
  • Score of 4+ on the SARC-F predict poor functional outcomes

Assess sarcopenia in the inpatient setting.

• These patients will often fail the “eyeball test”
• The sit-to-stand is useful in this environment
• Can use a “failure” as a springboard
  • One can cite this as a physical deficit and then ask what the patient would like to do at home which they cannot currently do and turn the encounter into a brief motivational interview  

Association between sarcopenia and other disease states.

• Inflammatory conditions in particular seem to have an association with sarcopenia
• Likely related to “anabolic resistance” (McKee et al 2017)
• Can lead to a sedentary lifestyle which also has mortality/morbidity implications (Carmeli 2017)

Current recommendations for physical activity:

• 2018 physical activity guidelines for adults ( Physical Activity Guidelines for Adults, 2nd ed.)
  • Twice weekly resistance training
  • 150-300 min of moderate intensity aerobic training or 75-150 min of vigorous training (based upon METS – 4-6 vs. 6+, respectively)
  • Updated in 2018, but recommendations have stayed the same
  • These are minimums! – There is a dose dependent relationship. More is generally better!
  • However, may need to scale back depending on comorbidities.
    • Example: a patient with moderate-to-severe COPD may not be able to achieve the minimum, but they may be more capable of resistance training than aerobic training due to their respiratory condition
    • In COPD – better correlation between quadriceps strength and mortality and FEV1 and mortality
• How do you talk to your patients about METS?
  • Respiratory rate of perceived exertion (Respiratory RPE or RPE,resp) (Wilson et al 1991)
    • Talk but cannot sing: moderate intensity (4-6 METS)
    • Can barely speak in short sentences: vigorous intensity (7+ METS)
• Steps?
  • No data to support the 10,000 steps
  • 4,000 steps/day has an impact on ASCVD risk (Lee et al 2019)
  • 7,500 steps/day has a greater impact on ASCVD risk (Lee et al 2019)

How do you get a chronically ill patient to start resistance training?

• Motivational interviewing is key
  • Ask your patient what they are willing to do, and start there, rather than “prescribing” a specific set of activities
  • Avoid terms like wear and tear that may set up your patient for failure
  • Use “age-related” changes, when appropriate
• If resistant to exercise, find out why!
• If a patient is concerned about pain, ask: Have you done a certain movement without pain? If so, could recommend using this movement as a means to begin resistance training by progressively loading the movement with a goal of increasing muscular strength and thus, physical function.
  • This may “convince”  your patient that they are capable of resistance training and that pain doesn’t have to be a limitation
• Consider referring: Not just to PTs, although they can be a great asset, but perhaps a strength coach/trainer in the community who is amenable to forming an alliance
  • There are obvious limitations/challenges here, but something to consider would be reaching out to a local gym to enquire about discounts for patients to ease access, and also providing that gym with some of the evidence-based guidance that we have regarding resistance training recommendations and the importance of sarcopenia
  • Admittedly, it is tough to “screen” the coach/trainer – would try to have a dialogue with a potential trainer to assess their experience and willingness to work with the population you hope to refer
  • With respect to PTs: it’s okay to provide them with specific recommendations and encourage them to push patients
• Isn’t resistance training dangerous?!
  • Walking is underdosed, not enough, and not-evidence based
    • Choosing Wisely & American Physical Therapy Association: Do not prescribe underdosed interventions
  • Encourage patient to start “low” and scale when able, with guidance/coaching
• Dr. Baraki: Think about your exercise counseling “NNT (number needed to treat)”
  • How many patients do you need to counsel in order to  improve your NNT and get more patients exercising?

Diet counseling and sarcopenia

• Generally, patients are not eating enough protein
  • The minimum amount of protein discussed in an ESPEN endorsed recommendation  from 2014 is 0.8gm protein/kg of body weight / day (Deutz et. al 2014)
  • The same guidelines recommend 1.0-1.2gm of protein/kg of body weight/day in older adults (>65 y/o) and 1.2-1.5 gm of protein/kg of body weight/day in those with severe illness or injuries
  • Why? Dr. Feigenbaum: Older adults tend to eat less protein AND have more anabolic resistance. Why do they suffer from greater anabolic resistance? Possibly from less efficient blood flow relative to younger patients, which in turn results in them being less efficient at extracting amino acids from the gut, resulting in a less robust increase in blood levels of amino acids, AND an overall reduction in transfer of amino acids to the skeletal muscle.
• Dr. Feigenbaum: Based on literature and personal experience, 1.6 gm protein/kg of body weight/day seems to maximize strength gains from resistance training. This protein can come from any source, both plant and non-plant based and supplemented with bars, shakes, etc. when needed.
  • Dr. Feigenbaum also states that in patients who need to keep protein intake low, such as certain CKD patients, skewing their intake towards essential amino acids is advisable (those which we cannot synthesize: histidine, isoleucine, leucine, lysine, methionine, phenylalanine, threonine, tryptophan, and valine)
  • How to estimate? A “palm-sized” portion of protein is, on average, 30gm of protein
• How do we assess for results?
  • Dr. Feigenbaum:  There is enormous variability between individuals and it is difficult to predict who will respond well to a given “dose” of resistance training and appropriate protein intake. There is data to show that, while underdosing is not advisable, a formal program where resistance training and protein intake are monitored, results in increases in muscle mass and strength – i.e. something is better than nothing!
    Dr. Baraki: If a patient doesn’t “respond” consider heightened anabolic resistance which may suggest the patient is closer to cachexia. In those patients, you need to try to increase the “dose” of therapy (protein, resistance training, etc.). 

Parting Thoughts:

Dr. Feigenbaum: 

Clinicians should try to identify patients who are at risk or actively suffering from sarcopenia and attempt to get patients motivated to exercise. Clinicians should be familiar with the minimum recommendations for physical activity (both resistance training and aerobic training) and be familiar with protein recommendations.

Dr. Baraki: 

Clinicians should focus on a practical approach – Consider crafting a narrative around activity and strength training that is meaningful. Don’t tell a patient they have a bunch of “wear and tear” and that they need to start lifting weights – that doesn’t make sense! Encourage patients that physical activity is safe when appropriately dosed with gradual loading.

Goal

By the end of this episode, listeners will be familiar with sarcopenia as an important clinical entity, the risk factors for sarcopenia, how to assess a potential sacropenic patient and how to provide treatment and counsel towards preventing or reversing sarcopenia. 

Learning objectives

After listening to this episode listeners will…  

1. Appreciate the clinical relevance/importance of sarcopenia
2. Know who is at risk for sarcopenia and how to screen them
3. Master the most recent exercise and nutrition recommendations for adults
4. Be familiar with motivational interviewing techniques to help promote diet and exercise changes to combat sarcopenia

Links*

1. Explain Pain – Book Recommendation, Dr. Baraki
2. Explain Pain – Supercharged – Book Recommendation, Dr. Baraki
3. Range: Why Generalists Triumph in a Subspecialized World – Book Recommendation, Dr. Feigenbaum
4. The Sports Gene: Inside the Science of Extraordinary Athletic Performance – Book Recommendation, Dr. Feigenbaum
5. The Mind’s Eye – Book Recommendation, Dr. Feigenbaum
6. Bacterionomicon: The Creatures of the Healing Blade – Book Recommendation, Dr. Brigham

*The Curbsiders participates in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising commissions by linking to Amazon. Simply put, if you click on my Amazon.com links and buy something we earn a (very) small commission, yet you don’t pay any extra.

References

1. Cruz-jentoft AJ, Baeyens JP, Bauer JM, et al. Sarcopenia: European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People. Age Ageing. 2010;39(4):412-23.
2. Cruz-jentoft AJ, Bahat G, Bauer J, et al. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing. 2019;48(1):16-31.
3. Cesari M, Calvani R, Marzetti E. Frailty in Older Persons. Clin Geriatr Med. 2017;33(3):293-303.
4. Evans WJ, Morley JE, Argilés J, et al. Cachexia: a new definition. Clin Nutr. 2008;27(6):793-9.
5. Emami A, Saitoh M, Valentova M, et al. Comparison of sarcopenia and cachexia in men with chronic heart failure: results from the Studies Investigating Co-morbidities Aggravating Heart Failure (SICA-HF). Eur J Heart Fail. 2018;20(11):1580-1587.
6. Choi KM. Sarcopenia and sarcopenic obesity. Korean J Intern Med. 2016;31(6):1054-1060.
7. Ilich JZ, Kelly OJ, Inglis JE. Osteosarcopenic Obesity Syndrome: What Is It and How Can It Be Identified and Diagnosed?. Curr Gerontol Geriatr Res. 2016;2016:7325973.
8. Tanishima S, Hagino H, Matsumoto H, Tanimura C, Nagashima H. Association between sarcopenia and low back pain in local residents prospective cohort study from the GAINA study. BMC Musculoskelet Disord. 2017;18(1):452.
9. Sousa-santos AR, Amaral TF. Differences in handgrip strength protocols to identify sarcopenia and frailty – a systematic review. BMC Geriatr. 2017;17(1):238.
10. Alcazar J, Losa-reyna J, Rodriguez-lopez C, et al. The sit-to-stand muscle power test: An easy, inexpensive and portable procedure to assess muscle power in older people. Exp Gerontol. 2018;112:38-43.
11. Podsiadlo D, Richardson S. The timed “Up & Go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39(2):142-8.
12. Chen LK, Liu LK, Woo J, et al. Sarcopenia in Asia: consensus report of the Asian Working Group for Sarcopenia. J Am Med Dir Assoc. 2014;15(2):95-101.
13. Kuriyan R. Body composition techniques. Indian J Med Res. 2018;148(5):648-658.
14. Pagotto V, Santos KFD, Malaquias SG, Bachion MM, Silveira EA. Calf circumference: clinical validation for evaluation of muscle mass in the elderly. Rev Bras Enferm. 2018;71(2):322-328.
15. Malmstrom TK, Miller DK, Simonsick EM, Ferrucci L, Morley JE. SARC-F: a symptom score to predict persons with sarcopenia at risk for poor functional outcomes. J Cachexia Sarcopenia Muscle. 2016;7(1):28-36.
16. Mckee A, Morley JE, Matsumoto AM, Vinik A. SARCOPENIA: AN ENDOCRINE DISORDER?. Endocr Pract. 2017;23(9):1140-1149.
17. Carmeli E. Frailty and Primary Sarcopenia: A Review. Adv Exp Med Biol. 2017;1020:53-68.
18. Wilson RC, Jones PW. Long-term reproducibility of Borg scale estimates of breathlessness during exercise. Clin Sci. 1991;80(4):309-12.
19. Lee IM, Shiroma EJ, Kamada M, Bassett DR, Matthews CE, Buring JE. Association of Step Volume and Intensity With All-Cause Mortality in Older Women. JAMA Intern Med. 2019.
20. Deutz NE, Bauer JM, Barazzoni R, et al. Protein intake and exercise for optimal muscle function with aging: recommendations from the ESPEN Expert Group. Clin Nutr. 2014;33(6):929-36.

Disclosures

Dr. Feigenbaum is the owner of Barbell Medicine LLC which provides free, paid and retail content to include strength/nutrition coaching, strength/nutrition seminars, shirts, training gear and protein / pre-work out supplements.

Dr. Baraki works part-time for Barbell Medicine LLC as a writer and coach for which he is paid. He does not receive any proceeds from the sale of supplements or other retail goods. 

Citation

Askin C, Baraki A, Feigenbaum J, Williams PN, Brigham SK, Watto MF. “#186 Sarcopenia: Raising the Bar in Primary Care”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list. December 2, 2019.