Submitted: April 30, 2016 Posted: June 20, 2016

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1 111 Submitted: April 30, 2016 Posted: June 20, 2016 TITLE: Prevalence of sarcopenia in a hospital based weight management center in the Philippines AUTHORS: Maricar Esculto MD (1), Kevin Carpio RND (3), Maria Nenita Umali RND (2), Iree Velasco RND (1,2), Eduardo Oliveros MD (2), Leonora Panlasigui PhD (3) and Luisito Llido MD (1,2,3) INSTITUTION WHERE STUDY WAS DONE: 1. Clinical Nutrition Service, St. Luke s Medical Center, E. Rodriguez Avenue, Quezon City, Philippines, Weight Management and Bariatric- Metabolic Surgery Center, St. Luke s Medical Center,E. Rodriguez Avenue, Quezon City, Philippines School of Nutrition, Philippine Women s University, 743 Taft Avenue, Manila, Philippines ABSTRACT: Background of the Study: Sarcopenia is associated with poor outcomes hence its diagnosis is important because of its impact on morbidity and mortality. Prevalence studies have been published in the U.S. and the Asia Pacific region but there is no data on sarcopenia in the Philippines. Objectives of the Study: a) To determine the body composition reference data (skeletal muscle mass and index) from a normal Filipino population composed of students from a university in Manila, Philippines, the Philippines Women s University and deriving the sarcopenia cut- off values from this data. b) To determine the prevalence of sarcopenia among patients seen in the Weight Management Center of St. Luke s Medical Center, Quezon City, Philippines using the data from the local reference population. Methodology: Demographic, anthropometric and Bioelectrical Impedance Analysis (BIA) data of one thousand six hundred five subjects seen in the Weight Management and Bariatric- Metabolic Surgery Center of St. Luke s Medical Center, Quezon City, Philippines from 2003 to 2010 were analyzed for this study. From these data, the Skeletal Muscle Mass (SM in kg) and Index (SMI) was determined and based from the cut- off values from a normal healthy control population (N=115, students aged 18 to 25 years old, male and female, with a BMI range from 18.5 to 25) the diagnosis of sarcopenia is made. Sarcopenia 1 means the SMI falls one standard deviation below the mean SMI values of each gender from the normal population; it is Sarcopenia 2 if it is two standard deviations below the normal mean. Results: The cut- off values are as follows: between 8.54 and 7.93 for males and between 6.3 and 5.87 for females to diagnose Sarcopenia Type 1 and below 7.93 for males and below 5.87 for females for Sarcopenia Type 2. Only 0.3% (5/1,605) of the total population was found to have Sarcopenia Type 1. Three out of 144 elderly (2.1%) has Type 1 Sarcopenia. Sarcopenia Type 1 was not seen among the obese. Sarcopenia Type 2 was not seen in this population. In reference to the nutritional status, three of the underweight subjects (3/25 or 12%) and two who have normal BMI (2/191 or 1.05%) were diagnosed to have Type 1 Sarcopenia. No diagnosis of sarcopenia was made among the overweight and obese subjects. Over- all sarcopenia for

2 112 males was 1/572 or 0.17% while for females it was 4/1,033 or 0.4%; overall sarcopenia rate was 5/1,605 or 0.3%. Among the elderly it was 3/144 or 2.08%. Conclusion: The study was able to determine the cut- off values to diagnose sarcopenia from the body composition reference data of a normal Filipino population. It was found that there is a lower prevalence of sarcopenia among the Filipino subjects compared to their other Asian counterparts. KEYWORDS: sarcopenia, obesity, BMI, body composition INTRODUCTION Sarcopenia is a syndrome characterised by progressive and generalised loss of skeletal muscle mass and strength. This condition is associated with a risk of adverse outcomes such as physical disability, poor quality of life and death due to the underlying diminished lean body mass, commonly present in the elderly. (1) In critical care patients with mechanical ventilator support, sarcopenic patients had lesser ventilator free days, shorter ICU free days and higher mortality (2x) compared to non- sarcopenic patients. (2) In colorectal surgery cancer patients, those with sarcopenia had more cardiac arrhythmias, hypertension, COPD, diabetes and fluid and electrolyte disorders. (3) Finally in emergency surgery elderly patients, it was noted that those without sarcopenia had lower mortality rates thus making the presence or absence of sarcopenia a predictive factor on outcome(s). (4) It is therefore important to identify the presence of sarcopenia in order to have a good predictive capability in terms of critical care, post- surgical management including the care of the elderly patient population. The European Working Group on Sarcopenia in Older People (EWGSOP) has designed an algorithm on how to identify the presence of sarcopenia in order to make prognostic decisions and making the necessary building up or maintenance to improve outcomes (Figure 1). (1) Figure 1: Algorithm for the diagnosis of sarcopenia (1)

3 113 The table below shows the suggested examinations to determine and/or evaluate skeletal muscle mass and function (Table 1) Variable Research Clinical Practice CT BIA MRI DXA Muscle Mass DXA Anthropometry BIA (Bioeletric Impedance Analysis) Body Potassium Handgrip strength Handgrip strength Muscle Strength Knee flexion/extension Peak expiratory flow SPPB (Short Physical Performance Battery ) SPPB Physical Usual gait speed Usual gait speed Performance Timed get- up- and- go test Get- up- and- go test Stair climb power test Legend: CT=computerized tomography; MRI=magnetic resonance imaging; BIA=bioelectric impedance analysis; DXA=dual- energy x- ray absorptiometry; SPPB=short physical performance battery The examinations in the research setting are more rigid and extensive, but the examinations recommended for use in clinical practice are more practical and affordable. Among these are anthropometry, BIA, handgrip strength, and the gait speeds. Body composition analysis is used more frequently nowadays thus the need for easier to perform examinations using equipment which are less expensive and portable. The BIA machine was evaluated and found to have good results when validated from the studies done by Heymsfield, Baumgartner (5) and Janssen (6). The formulas at arriving at the skeletal muscle mass based the BIA (bioelectrical impedance analysis) were derived by Janssen and the resulting formulation of the skeletal muscle index (SMI) has helped in the determination of sarcopenia in the population specifically the elderly and malnourished. Reports on the prevalence of sarcopenia in the U.S. have been published (13%- 24%) (5) and reports from the Asia Pacific region are also available (Table 2). (7-14) Country Taiwan (Chien) (7) Korea (Kim) (8) Japan (Sanada) (9) Japan (Tanimoto) (10) Year Total Population Table 2: Prevalence of sarcopenia in Asia (mixed) 18-90y BIA Male; 328 Female 1488 (mixed) 364 Male, 794 Female Age Method Cut- off 60 y, 20-88y 18-85y 74.4y M (mean); 73.9y F (mean) DXA DXA <8.87 Male, <6.42 Female <7.40 Male, <5.14 Female <6.87 Male, <5.46 Female Sarcopenia Prevalence (%) Male Female Overall Class I 6.7, Class Class I 6.3, Class BIA

4 114 Malaysia (Norshafarina (11) Taiwan (Lee) (12) China (Meng) (13) Japan (Yamada) (14) (mixed) 60 y BIA Male; 163 Female 73.7y (mean) <8.5 Male, <5.75 Female DXA M > 80y DXA < Male; 1314 Female 74.9y (mean) BIA There is no data on sarcopenia in the Philippines and with the rising prevalence of obesity in Asia it was deemed important to know if sarcopenia is present in this group of patients in the country. BIA is relatively common in the wellness units in the hospitals, thus there is a wealth of data available to analyze the cut- off values of sarcopenia and thus to come up with the local prevalence of sarcopenia in the elderly and the obese population. The objectives of this study are: a) To determine the body composition reference data (skeletal muscle mass and index, fat mass, fat free mass and total body water) from a normal population composed of students from a university in Manila, the Philippines Women s University, and b) To determine the prevalence of sarcopenia among patients seen in the Weight Management Center of St. Luke s Medical Center, Quezon City using the BIA data from the patients and local reference population. METHODOLOGY: The health care unit where the study was done was the Weight Management and Bariatric- Metabolic Surgery Center of St. Luke s Medical Center, Quezon City, Philippines. The center s main aim is to manage the body composition of obese and underweight patients through a multidisciplinary approach. It is run by a team composed of physicians, dietitians, nurses and physical therapists. It also offers wellness packages and health maintenance care. Records of all patients seen at the center from 2003 to 2010 were reviewed. The data gathered from the patients from this study are: height in meters, weight in kilograms, BMI, and Bioelectric Impedance Analysis (BIA) data. These are encoded into a data base using Microsoft Access version Body composition was measured using a BIA machine (Tanita brand) which measures the fat free mass, fat mass, impedance value and total body water. It does the measurements with the patients standing up. Sarcopenia is determined by getting the skeletal muscle mass of the patients using the Janssen equation for skeletal muscle mass. (6) This is the formula for skeletal muscle mass or SM: SM mass (kg) = [(Ht 2 /R) x 0.401) + (gender x 3.825) + (age x )] where Ht is height in centimeters; R is BIA resistance in ohms; for gender, men = 1 and women = 0; and age is in years. Once this is obtained the Skeletal Muscle Index or SMI of the patient is determined and Sarcopenia Type 1 or Type 2 is diagnosed if the patient s SMI falls below the Sarcopenia Type 1 or Sarcopenia Type 2 cut- off values. This is the formula for the SMI:

5 115 Skeletal Muscle Index (SM) = Skeletal Muscle Mass (SM) in kg divided by the square of the Height in meters or SMI = SM/Ht 2 The cut- off values are taken from SMI measurements from a normal healthy control population which in this case are students aged 18 to 25 years old, male and female, with a BMI range from 18.5 to 25 enrolled in the Philippine Women s University (PWU). (To be published) The standard deviations from the mean SMI of the male and female control populations are determined and the sarcopenia cut- off values are shown in the table below (Table 3): Table 3: Data from the normal control population Normal reference population (n=115) Men Women Total number Age (Std Dev) (1.86) (1.63) Mean BMI (Std Dev) (1.98) (1.93) Mean weight (kg) (Std Dev) (6.64) (5.34) Mean height (cm) (Std Dev) (6.24) (5.39) Mean SM or skeletal muscle mass in kg (Std Dev) (2.22) (1.34) Mean SMI (kg/m2) Std Dev of SMI /2 Std Dev of SMI Type 1 Sarcopenia cut off (1/2 of the SMI Std Dev) Type 1 sarcopenia cut- off Type 2 sarcopenia cut- off <7.93 <5.87 We arbitrarily assigned a one half (1/2) of the standard deviation cut- off to determine if it will be sensitive enough to show more sarcopenic patients in as much as the suggested cut- off values by Janssen (16) and used by Malaysia group (11) showed more sarcopenia patients. (Table 2) The main issue with the Filipino data was that the mean SMI of the reference Filipino population was lower than the Janssen cut- off values (9.16 kg/m2 vs kg/m2 for males) or equal (6.74 kg/m2 vs kg/m2 for females). Utilizing the ½ and 1 standard deviation cut- off is done to find out if there is a significant difference in the resulting numbers. RESULTS: One thousand six hundred five subjects were included in the study (572 males, 1,033 females). Among the population, 59.4% are obese (n=953; 412 males, 541 females). Those aged 60 years and above comprise 144 and they are classified as the elderly population (58 males, 86 females). One hundred one (101) of the subjects are found to be both elderly and obese (43 males, 58 females). Sarcopenia was identified in 5 of the subjects and among them, 3 belong to the elderly. No obese subject was found to have sarcopenia. Shown in the following tables are the data on sarcopenia from the Weight Management Center:

6 116 Table 4: Sarcopenia Data for Male Patients Total Patients = 1,605 Men Men Men Criteria Janssen PWU (1 Std Dev) PWU (1/2 Std Dev) Total per gender group SMI Sarcopenia 1 Cut- Off <10.75 kg/m2 = 109 <8.54 kg/m2 = 1 <8.85 kg/m2 = 2 Sarcopenia Type 1 Rate (All Age Groups) 19.06% 0.17% 0.35%% UW = 25 7 (28%) 1 (4%) 1 (4%) NOR = (14%) 0 (0%) 1 (0.5%) OW = (10%) 0 (0%) 0 (0%) OB = (3%) 0 (0%) 0 (0%) Total Elderly = SMI Sarcopenia 1 Cut- Off for Elderly <10.75 kg/m2 = 14 <8.54 kg/m2 = 1 <8.85 kg/m2 = 1 Sarcopenia Type 1 Rate (Elderly) 24.14% 1.72% 1.72% UW = 4 3 (75%) 1 (25%) 1 (25%) NOR = 9 2 (22.2%) 0 (0%) 0 (0%) OW = 46 4 (8.7%) 0 (0%) 0 (0%) OB = 84 5 (6%) 0 (0%) 0 (0%) Table 5: Sarcopenia Data for Female Patients Total Patients = 1,605 Women Women Women Criteria Janssen PWU (1 Std Dev) PWU (1/2 Std Dev) Total per gender group SMI Sarcopenia 1 Cut- Off <6.75 kg/m2 = 13 <6.3 kg/m2 = 4 <6.52 kg/m2 = 6 Sarcopenia Type 1 Rate (All Age Groups) 1.26% 0.40% 0.58% UW = 25 5 (20%) 2 (8%) 3 (12%) NOR = (2.6%) 2 (1%) 3 (1.6%) OW = (0.7%) 0 (0%) 0 (0%) OB = (0%) 0 (0%) 0 (0%) Total Elderly = 143 SMI Sarcopenia 1 Cut- Off For Elderly <6.75 kg/m2 = 5 <6.3 kg/m2 = 2 <6.52 kg/m2 = 2 Total Per Gender Sarcopenia Type 1 Rate (Elderly) 5.80% 2.30% 2.30% UW = 4 0 (0%) 0 (0%) 0 (0%)

7 117 NOR = 9 3 (33%) 2 (22%) 2 (22%) OW = 46 2 (4.3%) 0 (0%) 0 (0%) OB = 84 0 (0%) 0 (0%) 0 (0%) As shown in Tables 3 and 4 there was an increase in the number of sarcopenia patients when the cut- off was reduced to ½ of the standard deviation of the normal Filipino control data indicating that although minimal this change may be more reflective of sarcopenia in this population. The suggested cut- offs by Janssen et al are not appropriate for this Filipino population group. Table 6: Summary: sarcopenia from the general population, obese, elderly and elderly- obese population. Group Number Sarcopenia Type 1 Sarcopenia Type 2 A. General population 1,605 5/1,605 or 0.3% Male 572 1/572 or 0.17% Female 1,033 4/1,033 or 0.4% B. General OBESE population 948 /1605 (=59.1%) 0/948 or 0% Male 410 0% Female 538 0% C. Elderly population 143 /1605 (=9%) 3/143 or 2.1% 0% (60 y/o and above) Male 58 1/58 or 1.7% Female 86 2/86 or 2.3% D. Elderly OBESE population 101 /143 (=70%) 0/101 or 0% Male 43 0/43 or 0% Female 58 0/58 or 0% The prevalence of sarcopenia was also computed based on the nutritional status. Twenty five out of 1,605 subjects (1.6%) were underweight and three of them were diagnosed to have Type 1 Sarcopenia. One hundred ninety one of the subjects (11.9%) had normal BMI and two of them have Type 1 Sarcopenia. No diagnosis of Sarcopenia was found among the overweight and obese subjects. These are the data on sarcopenia in the different nutritional status groups (BMI based) Table 7: Sarcopenia in the different nutritional status groups. Nutritional Status BMI based Number N=1605 Sarcopenia 1 by Gender Over- All Sarcopenia 1 Underweight (<18.5) 25 Male = 1/7 or 14% 3/25 (1.6%) Female = 2/18 or 11.1% (12%) Normal ( ) 191 Male = 0/32 or 0% 2/191 (11.9%) Female = 2/159 or 1.26% (1.05%) Overweight ( ) 441 Male = 0/121 or 0% 0/441 (27.5%) Female = 0/320 or 0% (0.0%) Obese ( 30) 948 Male = 0/410 or 0% 0/948 (59%) Female = 0/538 or 0% (0.0%)

8 118 DISCUSSION: BIA measurement is an integral part of the assessment of patients referred to the weight management center where the current study is done. Various definitions for sarcopenia are available and some require additional evaluation for muscle strength and physical performance which, unfortunately are not routinely done in the evaluation of patients in some centers. (1, 15) In this retrospective study where only the skeletal muscle mass may be derived from the available data, the method of Janssen was used for the diagnosis of Sarcopenia. In the literature, cut off for Sarcopenia among elderly Hispanic and white men and women are 7.26 kg- m- 2 and 5.45 kg- m- 2 respectively. (5) In another study among non- Hispanic whites, non- Hispanic blacks and Mexican American, the cut- offs are at <8.50 kg/m2 for men and <5.75 kg/m2 for women for severe sarcopenia. Various cut- off points were also computed in studies done in other Asian countries (7,8,9,11,13) and these are summarized in Table 2. The prevalence of sarcopenia among the Asian population ranges from 6.3% to 89% in men and 4.1% to 40.3% in women (Table 2) (7-14) Our results showed that the cut- off values for sarcopenia were <8.54 kg/m2 in men and <6.3 kg/m2 in women. The female and male cut- off falls within the range of the cut- offs from the other Asian countries. In terms of prevalence, only 0.3% of the total population was diagnosed to have sarcopenia type 1 and there was no diagnosis of sarcopenia type 2. Sixty percent (3/5) of the identified sarcopenic in the population belongs to the elderly age group (more than 60 years). This is consistent with the observation of Baumgartner and Janssen that the prevalence of sarcopenia increases with age but considering the total prevalence among the elderly subjects in this study, the results are relatively low (1.7% in elderly male, 2.3% in elderly female, 2.1% of the overall elderly subjects) compared to previous studies where it was noted that prevalence increased from 13% to 24% in persons under 70 years of age to >50% in persons over 80 years of age (5) and 45% and 59% respectively for men and women aged 60 years and above (class I sarcopenia). (16) No diagnosis of sarcopenia was seen among the obese population. This might be reflective of the findings in the study of Baumgartner wherein there was a significant protective association for obesity in both men and women (Odds Ratio: 0.11 and 0.07 respectively. (5) None of the previous studies reviewed related sarcopenia with nutritional status. In this study, we also determined the prevalence of sarcopenia based on the nutritional status (BMI based WHO criteria) and it was found that most of the subjects who were diagnosed to have sarcopenia belong to the underweight group (12% of total underweight subjects). The most plausible explanation for this is that loss of muscle mass results to a decreased weight and lower BMI. However, inference based from this finding is difficult to arrive at because other factors which may contribute to weight changes such as exercise, adequacy of intake and presence of co- morbid conditions were not accounted. The present study has several limitations. First, the equation that was used for predicting the skeletal muscle mass of the subjects for this study, although used in other studies done in Asia (7,11), was derived from Caucasians and was stated to have the tendency to under predict the skeletal muscle mass of the Asian cohort (6) hence if this is the case, a lower computed skeletal muscle mass and a possible higher prevalence of sarcopenia is expected to be observed. As of this writing, no other predictive equations to

9 119 compute for the skeletal muscle mass using BIA data which is validated for the Asian population is available. Second, selection bias is a major limitation in this study due to the fact that majority of the subjects are overweight and obese patients who are referred to the center for weight management. This finding may, however, emphasize that sarcopenic obesity may be seen only in patients who are elderly and with chronic disease like cancer or chronic infections, not the patients in the wellness programs who have otherwise normal status and function. Lastly, factors that may affect body composition such as presence of co- morbidities, physical activity, diet and intake of certain medications are not known. CONCLUSION / RECOMMENDATION The study was able to determine the cut- off values to diagnose sarcopenia from the body composition reference data of a normal Filipino population. It was found that there is a lower prevalence of sarcopenia among the Filipino subjects compared to their other Asian counterparts. Computations of skeletal muscle index and comparing it to the reference values to be able to diagnose sarcopenia in institutions where BIA machines are readily available and accessible can readily be made and appropriate interventions can immediately be included in patient management. There is still a need for more data to get more sensitive results. Creation of our own validation studies for the Asian population is an area of great interest. REFERENCES: 1. Cruz- Jentoft AJ et al. Sarcopenia: European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People. Age and Ageing 2010; 39: Moisey LL, Mourtzakis M, Cotton BA, Premji T, Heyland DK, Wade CE, Bulger E, Kozar RA. Skeletal muscle predicts ventilator- free days, ICU- free days, and mortality in elderly ICU patients. Crit Care 2013; 17(5): R206. doi: /cc Lieffers JR, Bathe OF, Fassbender K, Winget M and Baracos VE. Sarcopenia is associated with postoperative infection and delayed recovery from colorectal cancer resection surgery. British Journal of Cancer 2012; 107: doi: /bjc Du Y, Karvellas C, Baracos V, Williams DC, and Khadaroo RG. Sarcopenia is a predictor of outcomes in very elderly patients undergoing emergency surgery. Surgery, 2014; 156(3: doi: /j.surg Baumgartner RN, Koehler KM, Gallagher D, Romero L, Heymstleld SB, Ross RR, Garry PJ, and Lindem RD. Epidemiology of Sarcopenia among the Elderly in New Mexico. Am J Epidemiol 1998; 147(8): Janssen I, Heymsfield SB, Baumgartner RN and Ross R. Estimation of skeletal muscle mass by bioelectrical impedance analysis..j Appl Physiol, 2000; 89: Chien MY, Huang TY, Wu YT. Prevalence of sarcopenia estimated by a bioelectrical impedance analysis prediction equation in community- dwelling elderly people in Taiwan. J Am Geriatr Soc. 2008; 56: Kim et. al. Prevalence of sarcopenia and sarcopenic obesity in Korean adults: the Korean sarcopenic obesity study. International Journal of Obesity, 2009; 33: ; doi: /ijo ; published online 30 June Sanada K, Miyachi M, Tanimoto M, Yamamoto K, Murakami H, Okumura S, Gando Y, Suzuki K, Tabat I, Higuchi M. A cross- sectional study of sarcopenia in Japanese men and women: reference values and

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