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      What is the best adjustment of appendicular lean mass for predicting mortality or disability among Japanese community dwellers?

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          Age-related declines in skeletal muscle mass and strength, representing “sarcopenia,” are a growing concern in aging societies. However, the prevalence of low muscle mass based on the height 2-adjustment has been shown to be extremely low, and a more appropriate definition of low muscle mass is needed, particularly for Asian women. The aim of this study was to explore the most appropriate adjustment of appendicular lean mass (ALM) for predicting mortality or disability risk using ALM or any of 5 adjustments of ALM among community-dwelling Japanese.


          Subjects comprised 1026 men and 952 women between 40 and 79 years old at baseline (1997–2000) who participated in the National Institute for Longevity Sciences - Longitudinal Study of Aging, Japan. ALM (kg) and 5 adjusted indices of ALM (ALM/leg length, ALM/height, ALM/height 2, ALM/weight, and ALM/body mass index [BMI]) were assessed at baseline. Disability was defined by long-term care insurance certification based on responses to a survey mailed in 2013, and death records were obtained as vital statistics until December 2014. Crude and adjusted Cox proportional hazard models were used to estimate hazard ratios for mortality or disability by sex-stratified quintiles of each ALM index (ALM and adjusted ALM) or sarcopenia-related indices. The area under the curve (AUC) was calculated with the multivariate-adjusted logistic regression model. Additionally, mixed-effects analyses were used to clarify the age-related ALM indices decline over 12 years ( n = 1838).


          Crude Cox proportional hazard models and multivariate-adjusted logistic model (AUC) indicated that higher ALM and ALM/BMI in women, and higher ALM, ALM/leg length, ALM/height, and ALM/BMI in men were associated with lower risks for mortality or disability than ALM/height 2. The mixed effect model indicated all ALM indices in men, and ALM, ALM/leg length, and ALM/height in women could better predict age-related lean muscle mass decline.


          Unadjusted ALM in women, and ALM/leg length, ALM/height, ALM/BMI, and ALM in men may be more appropriate for predicting future mortality or disability than ALM/height 2. Considering the age-related muscle mass decline, unadjusted ALM would be the first variable to assess, regardless of sex, in this Japanese cohort study.

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          The online version of this article (10.1186/s12877-017-0699-6) contains supplementary material, which is available to authorized users.

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          Most cited references 18

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          Alternative definitions of sarcopenia, lower extremity performance, and functional impairment with aging in older men and women.

          To compare two methods for classifying an individual as sarcopenic for predicting decline in physical function in the Health, Aging and Body Composition Study. Observational cohort study with 5 years of follow-up. Communities in Memphis, Tennessee, and Pittsburgh, Pennsylvania. Men and women aged 70 to 79 (N=2,976, 52% women, 41% black). Appendicular lean mass (aLM) was measured using dual energy x-ray absorptiometry, and participants were classified as sarcopenic first using aLM divided by height squared and then using aLM adjusted for height and body fat mass (residuals). Incidence of persistent lower extremity limitation (PLL) was measured according to self-report, and change in objective lower extremity performance (LEP) measures were observed using the Short Physical Performance Battery. There was a greater risk of incident PLL in women who were sarcopenic using the residuals sarcopenia method than in women who were not sarcopenic (hazard ratio (HR)=1.34, 95% confidence interval (CI)=1.11-1.61) but not in men. Those defined as sarcopenic using the aLM/ht(2) method had lower incident PLL than nonsarcopenic men (HR=0.76, 95% CI=0.60-0.96) and women (HR=0.75, 95% CI=0.60-0.93), but these were no longer significant with adjustment for body fat mass. Using the residuals method, there were significantly poorer LEP scores in sarcopenic men and women at baseline and Year 6 and greater 5-year decline, whereas sarcopenic men defined using the aLM/ht(2) method had lower 5-year decline. Additional adjustment for fat mass attenuated this protective effect. These findings suggest that sarcopenia defined using the residuals method, a method that considers height and fat mass together, is better for predicting disability in an individual than the aLM/ht(2) method, because it considers fat as part of the definition.
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            Criteria for Clinically Relevant Weakness and Low Lean Mass and Their Longitudinal Association With Incident Mobility Impairment and Mortality: The Foundation for the National Institutes of Health (FNIH) Sarcopenia Project

            Background. This analysis sought to determine the associations of the Foundation for the National Institutes of Health Sarcopenia Project criteria for weakness and low lean mass with likelihood for mobility impairment (gait speed ≤ 0.8 m/s) and mortality. Providing validity for these criteria is essential for research and clinical evaluation. Methods. Among 4,411 men and 1,869 women pooled from 6 cohort studies, 3-year likelihood for incident mobility impairment and mortality over 10 years were determined for individuals with weakness, low lean mass, and for those having both. Weakness was defined as low grip strength (<26kg men and <16kg women) and low grip strength-to-body mass index (BMI; kg/m2) ratio (<1.00 men and <0.56 women). Low lean mass (dual-energy x-ray absorptiometry) was categorized as low appendicular lean mass (ALM; <19.75kg men and <15.02kg women) and low ALM-to-BMI ratio (<0.789 men and <0.512 women). Results. Low grip strength (men: odds ratio [OR] = 2.31, 95% confidence interval [CI] = 1.34–3.99; women: OR = 1.99, 95% CI 1.23–3.21), low grip strength-to-BMI ratio (men: OR = 3.28, 95% CI 1.92–5.59; women: OR = 2.54, 95% CI 1.10–5.83) and low ALM-to-BMI ratio (men: OR = 1.58, 95% CI 1.12–2.25; women: OR = 1.81, 95% CI 1.14–2.87), but not low ALM, were associated with increased likelihood for incident mobility impairment. Weakness increased likelihood of mobility impairment regardless of low lean mass. Mortality risk patterns were inconsistent. Conclusions. These findings support our cut-points for low grip strength and low ALM-to-BMI ratio as candidate criteria for clinically relevant weakness and low lean mass. Further validation in other populations and for alternate relevant outcomes is needed.
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              Sarcopenia definitions considering body size and fat mass are associated with mobility limitations: the Framingham Study.

              Sarcopenia defined by lean mass has been inconsistently associated with disability in elders. Studies suggest that definitions should consider body size and additional influences of high fat mass (FM; sarcopenic-obesity). We examined sarcopenia accounting for body size, and sarcopenic-obesity, in relation to mobility limitations among 767 elderly men and women (mean age 79 years) from the Framingham Study. Whole-body dual-energy x-ray absorptiometry measured appendicular lean mass (ALM) and total FM in 1992-1995. Sarcopenia was defined in two ways: ALM/height squared (ALM/ht(2)) and ALM adjusted for height and FM (residuals). Sarcopenic-obesity categories (referent, obese, sarcopenic, and sarcopenic-obese) were defined by cross-classifying ALM/ht(2) and obesity (% body fat: more than 30 for men and more than 40 for women). Mobility limitation was defined as self-reported inability to walk one-half mile, climb stairs, or perform heavy housework. Sex-specific logistic regression calculated odds ratios (OR) and 95% confidence intervals (CI) for mobility limitation, adjusting for covariates. Sixteen percent of men and 30% of women had mobility limitation. Among men, both ALM/ht(2) (OR = 6.3, 95% CI = 2.5-16.1) and residuals (OR = 4.6, 95% CI = 2.0-10.5) sarcopenia were associated with increased limitation. For sarcopenic-obesity, odds of limitation was higher in sarcopenic (OR = 6.1, 95% CI = 2.2-16.9) and sarcopenic-obese categories (OR = 3.5, 95% CI = 1.0-12.7) but suggested no synergistic effect. In women, only residuals sarcopenia was associated with higher odds of limitation (OR = 1.8, 95% CI = 1.2-2.9). Low lean mass is associated with mobility limitations after accounting for body size and fat, and lean and FM have independent effects on mobility in elders. These findings support previous reports that sarcopenia definitions should consider body size and fat.

                Author and article information

                +81-562-46-2311 , otsuka@ncgg.go.jp
                BMC Geriatr
                BMC Geriatr
                BMC Geriatrics
                BioMed Central (London )
                5 January 2018
                5 January 2018
                : 18
                [1 ]ISNI 0000 0004 1791 9005, GRID grid.419257.c, Section of NILS-LSA (National Institute for Longevity Sciences–Longitudinal Study of Aging), Center for Gerontology and Social Science, , National Center for Geriatrics and Gerontology, ; 7-430 Morioka-cho, Obu, Aichi 474-8511 Japan
                [2 ]ISNI 0000 0004 1791 9005, GRID grid.419257.c, Department of Orthopedics, , National Center for Geriatrics and Gerontology, ; 7-430 Morioka-cho, Obu, Aichi 474-8511 Japan
                [3 ]GRID grid.440866.8, Faculty of Health and Medical Sciences, , Aichi Shukutoku University, ; 2-9 Katahira, Nagakute, Aichi 480-1197 Japan
                [4 ]GRID grid.444512.2, Graduate School of Nutritional Sciences, , Nagoya University of Arts and Sciences, ; 57 Takeyanoyama, Iwasaki-cho, Nisshin, Aichi 470-0196 Japan
                [5 ]ISNI 0000 0004 1791 9005, GRID grid.419257.c, Hospital, National Center for Geriatrics and Gerontology, ; 7-430 Morioka-cho, Obu, Aichi 474-8511 Japan
                © The Author(s). 2018

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                Funded by: the Japanese Ministry of Education, Culture, Sports, Science and Technology
                Award ID: 16H03264
                Award ID: 15K00857
                Award Recipient :
                Funded by: Longevity Sciences from the National Center for Geriatrics and Gerontology
                Award ID: 28-40
                Award Recipient :
                Research Article
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                © The Author(s) 2018

                Geriatric medicine

                japanese, skeletal muscle mass, sarcopenia, criteria, mortality, disability


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