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Geriatr Gerontol Int 2014; 14 (Suppl. 1): 5260

ORIGINAL ARTICLE

Epidemiology of sarcopenia among community-dwelling

older adults in Taiwan: A pooled analysis for a broader
adoption of sarcopenia assessments
I-Chien Wu,1,2 Cheng-Chieh Lin,2 Chao A. Hsiung,1 Ching-Yi Wang,3 Chih-Hsing Wu,4,5
Ding-Cheng Derrick Chan,6,7 Tsai-Chung Li,8 Wen-Yuan Lin,9 Kuo-Chin Huang,10 Ching-Yu Chen1,10
and Chih-Cheng Hsu1,11 for the Sarcopenia and Translational Aging Research in Taiwan (START)
Team*
1

Institute of Population Health Sciences, National Health Research Institutes, Miaoli County, 2Program for Aging, College of Medicine,
Graduate Institute of Biostatistics, College of Public Health, China Medical University, 3School of Physical Therapy and Center for
Education and Research on Geriatrics and Gerontology, Chung Shan Medical University, 9Department of Family Medicine, China Medical
University Hospital, 11Department of Health Services Administration, China Medical University and Hospital, Taichung, 4Department of
Family Medicine, National Cheng Kung University Hospital, 5Institute of Gerontology, National Cheng Kung University Medical College,
Tainan, Departments of 6Geriatrics and Gerontology and 7Internal Medicine, National Taiwan University Hospital, and 10Department of
Family Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
8

Aim: To develop cut-off points of muscle mass, gait speed and handgrip strength; and to examine the prevalence
of sarcopenia, and the relationship between sarcopenia stages and functional limitations and disability by using these
cut-off points.
Methods: We pooled individual participant data of 2867 community-dwelling older adults from five cohort studies.
We defined the cut-off point of a muscle mass index (ASM/ht2) as the values of two standard deviations below the
sex-specific means of a young population or as the 20th percentile of the sex-specific distribution in our study
population. The gait speed and handgrip strength cut-off points were defined as the 20th percentile of their
population distributions. We also measured functional limitations, using the Short Physical Performance Battery, and
the number of activities of daily living and instrumental activities of daily living difficulties.
Results: We identified the cut-off points of ASM/ht2, gait speed and handgrip strength. By applying these cut-off
points to our study population, the prevalence of sarcopenia varied from 3.9% (2.5% in women and 5.4% in men)
to 7.3% (6.5% in women and 8.2% in men). A higher sarcopenia stage was independently associated with a lower
summary performance score, as well as more activities of daily living and instrumental activities of daily living
difficulties (P < 0.05 for all).
Conclusions: The prevalence of sarcopenia in community-dwelling older adults is comparable with those in other
populations. A doseresponse relationship exists between sarcopenia stages and functional limitations/disability. The
European Working Group on Sarcopenia in Older People consensus definition using these cut-off points is suitable
for determining sarcopenia cases in the elderly population of Taiwan. Geriatr Gerontol Int 2014; 14 (Suppl. 1):
5260.
Keywords: disability evaluation, epidemiology, muscle, physical function, sarcopenia.

Introduction
Accepted for publication 5 November 2013.
Correspondence: Dr Chih-Cheng Hsu MD DRPH, Institute of
Population Health Sciences, National Health Research
Institutes, 35 Keyan Road, Zhunan, Miaoli County 35053,
Taiwan. Email: cch@nhri.org.tw
*Other members of the START Team are listed at the end of this
article.

52

doi: 10.1111/ggi.12193

The global population is aging, and disabilities later in

life are becoming an urgent health issue.1 Skeletal
muscles play a critical role in maintaining function later
in life.2 However, skeletal muscle mass declines with
age.2 Sarcopenia, the age-related loss of skeletal muscle
mass and function, is prevalent among older people,
and represents a major risk factor of disability, falls,
2014 Japan Geriatrics Society

Sarcopenia in an elderly population in Taiwan

mortality, and numerous other adverse health outcomes

in older adults.24 Therefore, the early recognition and
diagnosis of sarcopenia in a primary care setting can
enable identifying and treating vulnerable older adults at
an early stage of the disablement process.
Operational definitions and diagnostic criteria have
recently been proposed to facilitate the prompt recognition of sarcopenia in clinical practice.37 According to
the consensus developed by the European Working
Group on Sarcopenia in Older People (EWGSOP), the
diagnosis of sarcopenia requires the measurement of
three variables: muscle mass, physical performance and
muscle strength.6 A wide range of assessment techniques with varying costs, availability and ease of use are
available for measuring each of these sarcopenia variables.6 Assessment techniques that are economical,
readily available, reliable and simple facilitate the widespread adoption of current sarcopenia case-finding
strategies in different healthcare settings and large-scale
community-based epidemiological studies. Bioelectrical
impedance analysis, usual gait speed and handgrip
strength are measurement methods used to assess
muscle mass, physical performance and muscle
strength, respectively, and are extremely promising in
this regard.4,6,8,9
Sarcopenia is diagnosed in older adults with low
muscle mass plus poor physical performance or muscle
strength.6 The EWGSOP also proposed a staging
scheme for sarcopenia.6 However, whether the cut-off
points of the muscle mass estimate, usual gait speed and
handgrip strength determined in Western studies could
be applied to other populations with different ethnicities
or cultures remains unclear. That racial and ethnic differences in body composition and physical function
exist is well known.1014 The results of previous studies
have shown that the proper cut-off points of sarcopenia variables for Asians can differ from those for
Westerners.1523 In the consensus report, the EWGSOP
called for the reference values of sarcopenia variables for
populations worldwide.6 Because sarcopenia is believed
to represent a major cause of disability,6,7 sarcopenia
defined using cut-off points should be independently
associated with the early indicators of the disablement
process, as well as a greater degree of disability among
older adults. Specifically, a doseresponse relationship
should exist between sarcopenia stages, and the indicators of disability risk and severity.
To meet the urgent need of defining the subnormal
values of muscle mass and physical function for a
sarcopenia diagnosis in a rapidly aging Asian population, we pooled primary data from five major cohort
studies in Taiwan, as part of the Sarcopenia and Translational Aging Research in Taiwan (START) project.
This pooling project, with its large sample, provides a
unique opportunity to address issues that cannot be
addressed sufficiently in any single study. The purpose
2014 Japan Geriatrics Society

of the present study was to develop muscle mass, gait

speed and handgrip strength cut-off points based on
population distributions, which were then used in the
EWGSOP diagnostic criteria of sarcopenia to determine
its prevalence and relationship with functional health in
a large sample of community-dwelling older adults in
Taiwan.

Methods
Participants
We analyzed the individual participant data of 2867
community-dwelling older adults, which were collected
during baseline examinations of five cohort studies
carried out between 2003 and 2012 (Table 1). Details of
the designs and participant recruitment of these studies
have been published previously.2426 All of the cohort
studies required written informed consent, and were
approved by the respective institutional review boards.

Body composition
Body composition was measured using an 8-contact
electrode bioelectrical impedance analysis (BIA) device
(Tanita BC-418, Tanita, Tokyo, Japan), and followed
the standard procedure and the manufacturers instructions.27 This BIA device was used to measure the wholebody and segmental impedance ( 1) at a frequency of
50 kHz, and it provided valid muscle mass estimates (kg)
of each of the four extremities.8 Appendicular muscle
mass (ASM) was calculated as the sum of the estimated
muscle mass for the arms and legs. A relative skeletal
muscle mass index (ASM/ht2) normalized for height was
defined as the ratio of ASM (kg) and the height squared
(m2).4,6
For this analysis, we defined muscle mass cut-off
points according to the distribution of ASM/ht2 of a
young population comprising 998 healthy adults (aged
2040 years)16 or the study population. A participant
was considered to have low muscle mass if his or her
ASM/ht2 was below 2 standard deviations of the reference young adult values defined in previous studies
(6.76 kg/m2 for men and 5.28 kg/m2 for women).16
Alternatively, based on the definition by Delmonico
et al. and Newman et al.3,5 we examined the sex-specific
distribution of ASM/ht2 in our study population, and
participants with ASM/ht2 in the lowest 20% of the
sex-specific distribution were considered to have low
muscle mass.

Gait speed
Participants were observed taking a walk over a short
distance at their usual pace, starting from a standing
position, and an examiner timed the task by using a
|

53

54

(8.5)
(8.0)
(8.2)
(8.3)
(8.0)
(10.5)
(10.4)
(9.6)
(10.6)
(10.8)
61.1
60.9
61.7
62.5
58.8
43.6
51.9
55.9
46.6
51.9
73.4
74.2
74.3
74.5
76.0
2012
2009
2003
2008
2012
Taipei, Kaohsiung
Taichung
Hualien
Taichung
Kaohsiung
HALST
TCHS-E
IPFCEH
COMDLST
TOP

Community
Community
Community
Community
Community

713
1042
340
223
549

(%)

COMDLST, Community-dwelling Older Adults Mobility Disability Longitudinal Follow Up Study in Taichung CityDevelopment of a Mobility Disability Screening Tool
and Plan; HALST, Healthy Aging Longitudinal Study in Taiwan; IPFCEH, Investigation of Physical Function Status of Community Elderly Adults in Hualien city;
TCHS-E, Taichung Community Health Study-Elders; TOP, Tianliao Old People Study.

24.4
24.4
24.4
24.9
24.4
158.2
157.8
159.0
158.4
154.9

(3.4)
(3.6)
(3.2)
(3.5)
(3.8)

Mean (SD) body

mass index
(kg/m2)
Mean age
at entry
(years)
Year of starting
enrolment
No.
participants
n
Setting
Study location
Study

Table 1 Characteristics of the cohort studies included in the pooled analysis

Men

Mean (SD)
weight
(kg)

Mean (SD)
height
(cm)

I-C Wu et al.

handheld stopwatch that measured to the nearest hundredth of a second. The walking distance ranged from 3
to 5 m according to different study sites. The gait speed
was calculated as the walking distance (m) divided by
time (s). We examined the distribution of the gait speed
stratified according to the sex-specific median height.
Participants with a gait speed in the lowest 20% of the
sex- and height-specific distributions were considered
to have low gait speed.6,28

Handgrip strength
Handgrip strength (kg) was measured using standard
calibrated hand dynamometers.24,25 We calculated the
average grip strength of each hand, and the average grip
strength of the hand with superior performance or that
of the dominant hand was used for the analysis. We
examined the distribution of the handgrip strength
stratified according to sex-specific body mass index
(BMI) quartiles. Participants with a handgrip strength in
the lowest 20% of the sex- and BMI-specific distributions were considered to have low handgrip strength.6,28

Sarcopenia
We determined the presence of sarcopenia according
to the EWGSOP consensus definition.6 A diagnosis of
sarcopenia requires the presence of low muscle mass in
addition to a low handgrip strength or a slow gait speed.
Participants were considered to have severe sarcopenia
if all three of these criteria were present, whereas those
with low muscle mass, but without a low handgrip
strength or a slow gait speed, were considered to be in
the presarcopenia stage.

Functional health status

We assessed functional limitations by using the Short
Physical Performance Battery (SPPB).29 A participant
received a summary performance score on this scale,
with a higher score representing better performance. A
lower summary performance score predicts disability in
a linear fashion across the entire range of values.29 We
also assessed the perceived function in the activities of
daily living (ADL) and the instrumental activities of daily
living (IADL) by carrying out structured interviews with
the Katz Index, the Barthel Index and the LawtonBrody
Instrumental Activities of Daily Living Scale, which
evaluate the level of dependence in carrying out each
task.3032 The severity of a disability was defined using
the number of ADL (i.e. eating, transferring, personal
hygiene, bathing, walking, dressing and continence) and
IADL (i.e. shopping, housekeeping, handling finances,
food preparation, using transportation, using a telephone, doing the laundry and taking medication) that
the person was unable to carry out independently.33
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Sarcopenia in an elderly population in Taiwan

Covariates
The covariates were the participants age, sex, education
level (6 years or >6 years), smoking status (smoker or
non-smoker), obesity status and comorbidities. Participants who reported smoking cigarettes at the time of the
interview were defined as smokers. We calculated the
BMI as the bodyweight in kg divided by the square of
the height in m2, and categorized it according to the
definition of the Department of Health in Taiwan (BMI
2426.9 kg/m2 for overweight and BMI 27 kg/m2 for
obesity).34 Comorbidities were assessed by referring to
the self-reported physicians diagnosis, and included
hypertension, diabetes mellitus, stroke, heart disease,
arthritis, and chronic obstructive pulmonary disease.

Statistical analysis
Descriptive statistics were used to characterize the
population. All of the continuous variables are presented as the mean SD. Differences in continuous
variables among the groups were analyzed using oneway analysis of variance (ANOVA), whereas differences in
categorical variables (proportions) were analyzed using
2-tests.
We examined the relationship between the sarcopenia
severity/stage and the functional health measures by
applying linear regression analysis. We included the
following covariates in the adjusted model: age, sex,
education level, smoking status, obesity status,
comorbidities and cohorts. We estimated the adjusted
values of the summary performance score, and the
number of ADL and IADL difficulties according to the
sarcopenia severity/stages. In all of the analyses, differences were considered significant when P < 0.05. We
calculated 95% confidence intervals (CI), and reported
the CI for each parameter estimate. All of the analyses
were carried out using SPSS version 19.0 (SPSS,
Chicago, IL, USA).

Results
The mean SD value of the participants age was 74 6
years, and 50% of the participants were women. The
mean SD values of the sarcopenia variables were as
follows: ASM/ht2, 6.38 0.82 kg/m2 in women, and
8.05 1.15 kg/m2 in men; gait speed, 0.82 0.26 m/s in
women, and 0.90 0.27 m/s in men; and handgrip
strength, 20.0 5.4 kg in women, and 32.3 7.4 kg in
men. The cut-off points for low muscle mass, low
physical performance and low muscle strength are summarized in Table 2.
After applying the EWGSOP diagnostic criteria of
sarcopenia with muscle mass cut-off points derived
from reference young adults, we observed a prevalence
of sarcopenia of 2.5% among women and 5.4% among
2014 Japan Geriatrics Society

Table 2 Cut-off points of the sarcopenia variables

Cut-off points
Muscle mass (ASM/ht2)
Men
Women
Physical performance (gait speed)
Men
Height 163 cm
Height >163 cm
Women
Height 152 cm
Height >152 cm
Muscle strength (handgrip strength)
Men
BMI <22.1 kg/m2
BMI 22.124.3 kg/m2
BMI 24.426.3 kg/m2
BMI >26.3 kg/m2
Women
BMI <22.3 kg/m2
BMI 22.324.2 kg/m2
BMI 24.326.8 kg/m2
BMI >26.8 kg/m2

6.76 kg/m2
7.09 kg/m2
5.28 kg/m2
5.70 kg/m2

0.67 m/s
0.71 m/s
0.57 m/s
0.67 m/s

25.0 kg
26.5 kg
26.4 kg
27.2 kg
14.6 kg
16.1 kg
16.5 kg
16.4 kg

Defined as values two standard deviations below the

sex-specific means of the reference young adults aged 2040
years. Defined as the 20th percentile of the sex-specific
distribution in our study population. Defined as the 20th
percentile of the sex- and height-specific distribution in our
study population. Defined as the 20th percentile of the sexand body mass index (BMI)-specific distribution in our study
population. ASM, appendicular muscle mass.

men. The corresponding values were 6.5% in women

and 8.2% in men when using the muscle mass cut-off
points derived from the study population. As expected,
the prevalence of sarcopenia increased significantly with
age in both sexes (Table 3).
Participants with sarcopenia were more likely to be
older, lean and diagnosed with a chronic disease
(Table 4). Older adults at a more advanced stage of
sarcopenia tended to have a lower summary performance score as well as difficulties in more ADL and
IADL (Table 4). After adjusting for covariates, the
increasing sarcopenia level remained significantly associated with a lower summary performance score, and
more ADL and IADL difficulties (Table 5). Using
muscle mass cut-off points derived from the reference
young adults, we found that participants with severe
sarcopenia had a mean of 1.42 more ADL difficulties
(P < 0.001), a mean of 1.54 more IADL difficulties
(P < 0.001), and their summary performance score was a
mean of 2.5 points lower (P = 0.042) compared with
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55

56

Low muscle mass only. Low muscle mass + slower walking speed or low muscle mass + low handgrip strength. Low muscle mass + slower walking speed + low handgrip
strength. Sarcopenia + severe sarcopenia.

354 (74.1)
59 (12.3)
36 (7.5)
29 (6.1)
65 (13.6)
496 (86.0)
60 (10.4)
19 (3.3)
2 (0.3)
21 (3.6)
340 (78.2)
49 (11.3)
28 (4.6)
18 (4.1)
46 (10.6)
Muscle mass cut-off points derived from the study population
No sarcopenia
1732 (80.4)
882 (80.2)
542 (81.5)

266 (12.3)
147 (13.4)
98 (14.7)
Presarcopenia

105 (4.9)
50 (4.5)
22 (3.3)
Sarcopenia

52 (2.4)
21 (1.9)
3 (0.5)
Severe sarcopenia

157 (7.3)
71 (6.5)
25 (3.8)
Any sarcopenia

850 (80.6)
119 (11.3)
55 (5.2)
31 (2.9)
86 (8.2)

406 (84.9)
27 (5.6)
23 (4.8)
22 (4.6)
45 (9.4)
535 (92.7)
30 (5.2)
10 (1.7)
2 (0.3)
12 (2.1)
941 (89.2)
57 (5.4)
33 (3.1)
24 (2.3)
57 (5.4)
394 (90.6)
20 (4.6)
11 (2.5)
10 (2.3)
21 (4.8)

n (%)

Muscle mass cut-off points derived from reference young population

No sarcopenia
1964 (91.1)
1023 (93.0)
629 (94.6)

106 (4.9)
49 (4.5)
29 (4.4)
Presarcopenia

50 (2.3)
17 (1.5)
6 (0.9)
Sarcopenia

35 (1.6)
11 (1.0)
1 (0.2)
Severe sarcopenia

85 (3.9)
28 (2.5)
7 (1.1)
Any sarcopenia

Men
All ages
n (%)
Aged 75 years
n (%)
Aged 6574 years
n (%)
Women
All ages
n (%)
All

Table 3 Prevalence of sarcopenia using European Working Group on Sarcopenia in Older People definitions

Aged 6574 years

n (%)

Aged 75 years
n (%)

I-C Wu et al.

those without sarcopenia. We observed a similar pattern

when using the muscle mass cut-off points derived from
the study population (Table 5).

Discussion
In the present pooled analysis of five cohort studies, we
identified the cut-off points of a relative skeletal muscle
mass index, usual gait speed and handgrip strength,
based on the population distributions. The prevalence
of sarcopenia among community-dwelling older adults
was also estimated. Based on the staging scheme proposed by the EWGSOP, the sarcopenia severity/stage
was found to be related to degrees of functional limitations and disabilities in a doseresponse manner, independent of potential confounders.
The ASM/ht2 cut-off points derived from our reference young population were 6.76 kg/m2 for men and
5.28 kg/m2 for women, which are values similar to those
in a Japanese population (6.87 kg/m2 for men and
5.46 kg/m2 for women),23 although they were slightly
higher than those in a South Korean population
(6.58 kg/m2 for men and 4.59 kg/m2 for women)19 and a
Chinese population (6.08 kg/m2 for men and 4.79 kg/m2
for women).17 Slight variations in muscle mass distributions among young adults might be owing to differences
in early life determinants of peak muscle mass.35 The
use of muscle mass cut-off points derived from healthy
young adults is recommended; however, researchers
have suggested alternative methods of defining subnormal muscle mass.3,5,6 The ASM/ht2 values of 7.09 kg/m2
in men and 5.70 kg/m2 in women corresponded to the
20th percentile of the sex-specific distribution in our
study population. These values are similar to the ASM/
ht2 values identified in other populations comprising
older adults.3,5 Newman et al. noted that the ASM/ht2
values of 7.23 kg/m2 in men and 5.67 kg/m2 in women
represented the 20th percentile values in a USA population of older adults aged 70 years and older.5 In
general, the muscle mass cut-off points indentified in
the present study were congruent with previous studies
findings.
The mean gait speed in the present study was
0.90 0.27 m/s in men and 0.82 0.26 m/s in women.
This is in agreement with the results of studies that
had recruited elderly Chinese cohort populations.12
However, these estimates were lower than those
observed in Western populations.36,37 In a study that
recruited 1750 community-dwelling Caucasian older
adults aged 70 years and older, men had a mean gait
speed of 1.15 m/s, and women had a mean gait speed
of 1.08 m/s.37 The racial/ethnic differences in gait
speed values could partly be due to differences in
anthropometrics.11 Because gait speed is known to differ
significantly based on a persons sex and height,36,37 we
examined the distributions according to the sex-specific
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Sarcopenia in an elderly population in Taiwan

Table 4 Characteristics of study participants according to sarcopenia status (n = 2155)

Characteristics

No sarcopenia

Presarcopenia

Sarcopenia

Severe
sarcopenia

78.6 (7.3)
33 (66.0)

81.7 (6.2)
24 (68.6)

<.001
<.001
.034

24 (48.0)
4 (8.0)

18 (51.4)
3 (8.6)

48 (96.0)
1 (2.0)
1 (2.0)
6 (12.0)
24 (48.0)
21 (42.9)
1 (2.0)
7 (14.0)
1 (2.0)
0.16 (0.48)
0.64 (1.61)
9.9 (1.8)

33 (94.3)
1 (2.9)
1 (2.9)
5 (14.3)
18 (51.4)
11 (32.4)
6 (17.6)
8 (23.5)
3 (8.6)
1.71 (2.37)
2.14 (2.17)
7.7 (2.1)

73.9 (5.8)
119 (44.7)

77.4 (7.0)
55 (52.4)

81.4 (6.2)
31 (59.6)

92 (34.6)
34 (12.8)

45 (42.9)
7 (6.7)

29 (55.8)
3 (5.8)

89 (84.8)
13 (12.4)
3 (2.9)
11 (10.5)
52 (49.5)
39 (37.5)
7 (6.7)
18 (17.5)
1 (1.0)
0.19 (0.49)
0.54 (0.13)
9.4 (1.8)

39 (75.0)
11 (21.2)
2 (3.8)
14 (26.9)
27 (51.9)
17 (33.3)
7 (13.7)
12 (23.5)
3 (5.8)
1.33 (2.01)
1.63 (2.03)
5.33 (3.08)

Muscle mass cut-off points derived from reference young population

Age (years)
74.0 (6.0)
74.3 (6.4)
Men, n (%)
941 (47.9)
57 (53.8)
Education
6 years, n (%)
1089 (55.4)
42 (39.6)
Smoking, n (%)
140 (7.1)
16 (15.1)
BMI
Lean, n (%)
827 (42.2)
99 (93.4)
Overweight, n (%)
673 (34.3)
5 (4.7)
Obesity, n (%)
462 (23.5)
2 (1.9)
Diabetes mellitus, n (%)
367 (18.8)
14 (13.2)
Hypertension, n (%)
1034 (53.0)
34 (32.7)
Heart disease, n (%)
342 (17.6)
23 (21.7)
Stroke, n (%)
107 (5.5)
4 (3.8)
Arthritis, n (%)
387 (20.1)
9 (8.6)
Chronic obstructive pulmonary disease, n (%)
40 (2.1)
7 (6.6)
No. ADL difficulties
0.12 (0.44)
0.06 (0.24)
No. IADL difficulties
0.20 (0.73)
0.09 (0.38)
Summary performance score
10.1 (2.5)
10.5 (1.7)
Muscle mass cut-off points derived from the study population
Age (years)
73.9 (6.0)
Men, n (%)
850 (49.1)
Education
6 years, n (%)
1007 (58.1)
Smoking, n (%)
119 (6.9)
BMI
Lean, n (%)
650 (37.6)
Overweight, n (%)
623 (36.0)
Obesity, n (%)
457 (26.4)
Diabetes mellitus, n (%)
330 (19.2)
Hypertension, n (%)
927 (53.8)
Heart disease, n (%)
286 (16.7)
Stroke, n (%)
97 (5.7)
Arthritis, n (%)
347 (20.4)
Chronic obstructive pulmonary disease, n (%)
37 (2.2)
No. ADL difficulties
0.12 (0.45)
No. IADL difficulties
0.20 (0.73)
Summary performance score
10.1 (2.49)

229 (86.1)
33 (12.14)
4 (1.5)
37 (13.9)
104 (39.7)
55 (20.7)
7 (2.6)
34 (12.9)
10 (3.8)
0.06 (0.25)
0.08 (0.39)
10.8 (1.6)

.137
<.001

.086
.043
<.001
.197
.181
.004
<.001
<.001
.010
<.001
.189
<.001
.268
<.001

.223
.018
<.001
.297
.020
.211
<.001
<.001
<.001

Data are means (SD) unless otherwise specified. Low muscle mass only (n = 106 when muscle mass cut-off points were
derived from reference young population; n = 266 when muscle mass cut-off points were derived from the study population).

Low muscle mass + slower walking speed or low muscle mass + low handgrip strength (n = 50 when muscle mass cut-off
points were derived from reference young population; n = 105 when muscle mass cut-off points were derived from the study
population). Low muscle mass + slower walking speed + low handgrip strength (n = 35 when muscle mass cut-off points were
derived from reference young population; n = 52 when muscle mass cut-off points were derived from the study population).
ADL, activities of daily living; BMI, body mass index; IADL, instrumental activities of daily living.

median height. As expected, the gait speed cut-off

points corresponding to the 20th percentile of the distributions were typically lower than those identified in
Western populations,6,28 further emphasizing the need
for ethnicity- or population-specific norms for physical
performance measures.
2014 Japan Geriatrics Society

In the present study, older Taiwanese men had a

mean handgrip strength of 32.3 7.4 kg, and women
had a mean handgrip strength of 20.0 5.4 kg. Both
values were lower than those observed in Western
populations.13,14 This is consistent with the findings
from other Asian populations.38 To account for the
|

57

58

Data are means, and are adjusted for, age, sex, education level, smoking status, obesity, hypertension, diabetes mellitus, stroke, heart disease, arthritis, chronic obstructive
pulmonary disease and cohort. Low muscle mass only. Low muscle mass + slower walking speed or low muscle mass + low handgrip strength. Low muscle mass + slower
walking speed + low handgrip strength. ADL, activities of daily living; BMI, body mass index; CI, confidence interval; IADL, instrumental activities of daily living.

<0.001
<0.001
<0.001
6.0, 2.6
0.86, 1.19
0.74, 1.21
4.28
1.00
0.98
9.3
0.14
0.39
Muscle mass cut-off points derived from the study population
Summary performance score
10.1
10.7
No. ADL difficulties
0.13
0.06
No. IADL difficulties
0.22
0.08

5.8
1.16
1.2

2.5
1.42
1.54
7.6
1.55
1.74
9.7
0.14
0.55
Muscle mass cut-off points derived from reference young population
Summary performance score
10.1
10.6
No. ADL difficulties
0.13
0.06
No. IADL difficulties
0.20
0.11

Severe
sarcopenia
Sarcopenia
Sarcopenia Stages
No sarcopenia
Presarcopenia

Table 5 Multivariate analyses testing associations of sarcopenia stages with functional health status

Difference between
severe sarcopenia
and no sarcopenia

95% CI

4.96, 0.09
1.23, 1.62
1.26, 1.81

0.042
<0.001
<0.001

P for trend

I-C Wu et al.

effects of sex and BMI,13,39 the handgrip strength distributions were stratified according to the sex-specific BMI
quartiles, and we identified the 20th percentile of the
distribution in each stratum as the handgrip strength
cut-off point. Similarly to the gait speed, the handgrip
strength cut-off points identified in the present study
were lower compared with those obtained in Western
studies.6,28
According to the EWGSOP consensus definition, the
prevalence of sarcopenia in our study population varied
from 3.9% when using muscle mass cut-off points
derived from a young population to 7.3% when using
muscle mass cut-off points derived from our large
sample of community-dwelling older adults. In addition, the sarcopenia prevalence increased with age, with
the prevalence reaching 13.6% among older men aged
75 years and older. These findings are congruent with
the results of recent studies that have applied the
EWGSOP operational definition of sarcopenia in different populations. Lee et al. noted a prevalence of 7.8%
in a sample of 408 elderly Taiwanese participants aged
65 years and older.15 In an elderly UK population
with a mean age of 67 years, 4.6% of men and 7.9% of
women were found to have sarcopenia.40 A recent study
observed a prevalence of 5% in a USA population aged
7079 years.41 Legrand et al. showed that the prevalence
of sarcopenia was 12.5% in a European population aged
80 years and older.42
Our study showed that the sarcopenia severity/stage
is independently associated with the summary performance score, and the number of ADL and IADL difficulties. Older adults with a higher stage of sarcopenia
tended to have a lower summary performance score,
and more ADL and IADL difficulties. The observed
doseresponse relationship between the sarcopenia
stages, and the indicators of disability risk and severity
suggested a gradient of an increasing risk of disability
development and progression through these stages.
These results are in agreement with the working definition of sarcopenia, as well as the current understanding of its progression.6,41
The present study has a number of strengths. We
used a large sample of individual participant data from
multiple diverse populations of community-dwelling
older adults in this pooled analysis. We used techniques
that are simple, economical, and practical for measuring
muscle mass, muscle strength, and physical performance. This study is one of the few attempts to define
the cut-off points of all three sarcopenia variables, estimate the prevalence of sarcopenia in a rapidly aging
Asian population in accordance with the consensus
developed by the EWGSOP, and examine the relationship between the sarcopenia stages and the functional
health measures. Despite these strengths, the present
results should be interpreted with caution because of
several potential limitations. This was a cross-sectional
2014 Japan Geriatrics Society

Sarcopenia in an elderly population in Taiwan

study, thus, we were unable to establish causal relationships. Residual confounding by the unmeasured variables could not be excluded completely. In assessing the
disease status, we relied chiefly on self-reports regarding
the presence of a disease. The participating study
cohorts mainly consisted of community-dwelling older
adults who might be, overall, healthier than the agematched general population. Therefore, the findings
might not be generalizable to the entire elderly population. Similarly to the commonly used cut-off points for
defining sarcopenia,6,28 the gait speed and handgrip
strength cut-off points in the present study were developed based on their distributions in populations consisting of older adults. It would be of great interest for
future studies to examine the distributions of gait speed
and handgrip strength of a young population in Taiwan,
and compare the gait speed and handgrip strength cutoff points derived from healthy young adults with those
derived from other reference populations.
Gait speed was measured across varying distances in
the present study (3 m [n = 181], 4 m [n = 734], 4.572 m
[n = 533] and 5 m [n = 1012]). A total of 7.4% of the
participants received gait speed measurement over a
distance of 3 m. Some researchers questioned the validity of measuring gait speed in less than 4 m, particularly
when using a static start.43 More research is required to
standardize gait speed measurement in our population.
In conclusion, the present pooled analysis provided
population-specific cut-off points for low muscle mass,
low physical performance and low muscle strength.
After applying the sarcopenia variable cut-off points to a
large sample of community-dwelling older adults, we
observed prevalence estimates for sarcopenia that were
comparable with those in other populations. In addition, sarcopenia severity was positively and independently associated with the degrees of functional
limitations and disabilities. We recommend that the
cut-off points be used in future large-scale communitybased studies examining the predictive ability of
sarcopenia for multiple adverse health outcomes in
older adults, as well as international comparisons on the
prevalence of sarcopenia. These efforts will foster a
broader adoption of sarcopenia assessments in primary
care settings, and ultimately improve healthcare for
older adults.

Acknowledgements
We thank Ming-Shiang Wu and Yi-Fen Tsai for their
assistance in data management and statistical analysis.
Other members of the START project are as follows: Dr
Meng-Chih Lee, Center for Education and Research on
Geriatrics and Gerontology and School of Medicine,
Chung Shan Medical University, Taiwan; Dr Chia-Ing
Li, China Medical University; Ms Ching-I Chang, Mr
2014 Japan Geriatrics Society

Ming-Shiang Wu and Ms Yi-Fen Tsai, National Health

Research Institutes.

Disclosure statement
The authors declare no conflict of interest.

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2014 Japan Geriatrics Society