“People don’t decide their future, people decide their habits and their habits decide their future.”
– F.M. Alexander
Nine years ago (2010)1, the European Working Group on Sarcopenia in Older People (EWGSOP) published a definition of sarcopenia that has been widely used worldwide and this definition has fostered advances in the identification and care of people at risk or with sarcopenia. It was defined as a syndrome characterized by progressive and widespread loss of muscle mass and strength at risk of adverse outcomes such as physical disability, poor quality of life and death. Because the relationship between muscle mass and strength is not linear (the ability to generate strength is not only dependent of muscle mass), the criteria for its diagnosis included low muscle mass and low muscle function (i.e. strength or physical performance).
After learning that in 2016 sarcopenia was classified as a disease by the World Health Organization, as noted in the first part of this article, the EWGSOP22 updated its operational definition and various diagnostic strategies, considering now that muscle strength (measured by grip strength or the chair stand test) is the main parameter for measuring muscle function, even more important than the amount of muscle mass. Therefore, it is in this context that we justify the title of this article and reinforce the importance of sharing this message with all health professionals.
The implications of this condition on human health are several and widely known: increased risk of falls and fractures3,4; impairment of activities of daily living5; association with heart disease6; respiratory disease7 and cognitive dysfunction8; lower quality of life9; loss of independence10,11,12 and death13. In financial terms, public health costs have also been calculated in several papers. In a study by Janssen et. al.14, in 2004, the costs of sarcopenia in the United States were estimated at $ 18.5 billion annually, representing about 1.5% of total health costs. In a study conducted here in Portugal at the Hospital de Santo António in Porto and published in 201615, it was found that hospitalization costs associated with sarcopenia were higher by 58.5% for patients under 65 years and by 34% for patients aged 65 and over. More recently (2018), the Hertfordshire Cohort Study in the United Kingdom16 found that the costs associated with lack of muscle strength were estimated at £ 2.5 billion annually.
In the present scenario, where the phenotype of unhealthy aging is proliferating in the eyes of all industrialized nations, in which diseases such as hypertension, cancer, depression, Alzheimer’s disease and type II diabetes are destroying people’s lives, it is essential to adopt measures aimed at improving function of each individual rather than diagnosing illnesses and administering medicines which, in addition, do not help solving this problem, and may further aggravate their condition. We know that the main health problems are related to poor diet, physical inactivity, lack of sleep, excess alcohol, exposure to tobacco and polluted environments but also lack of movement quality, vigor and muscular strength.
The benefits of strength training in health are well supported in the scientific literature and the most important ones are: decrease in blood pressure; decreased risk of osteoporosis and sarcopenia; improvement of lipid profile; increased cardiorespiratory capacity; prevention and management of chronic pain; increased insulin sensitivity; improvement of wellbeing and self-confidence. Moreover, several studies17,18,19 have shown a strong and consistent correlation between increased strength and muscle mass with decreased mortality, reinforcing the fact that the decline in strength associated with the current levels of sedentarism and aging need to be addressed. Therefore, a well-designed strength training program that meets the individual’s competency and follows the principles of adaptation to training will improve all of the above health indicators and all the necessary physical qualities (strength, power, speed, agility, balance, coordination, mobility, endurance) to carry out the activities of our daily life. These are the parameters of physical function that are currently being proposed as biomarkers of aging in humans20.
Consequently, program design will be the determining factor in this equation. And while it is true that this process requires imperative knowledge of sports sciences, it must be borne in mind that it also requires field work and art in coaching. Instead of being so preoccupied with following the guidelines and looking for statistically significant results, we should be concerned that our approach is relevant to one’s life. Because we work with people. People who have time constraints to train. People with different family and professional responsibilities. People who have different lives from each other. People who have a host of metabolic and / or orthopedic problems that no randomized controlled trial can ever reproduce! Yes, this is a complex process.
Finally, we know that one of the mechanisms responsible for muscle atrophy, sarcopenia and aging is apoptosis, a form of programmed cell death and a fundamental process in aging. But when we train, eat and rest properly, we are sending a signal to our body to create an anabolic environment, an environment that enhances the release of growth factors and suppresses apoptosis. That is, strength training is a macroscopic growth factor that suppresses programmed cell death (i.e. apoptosis), but unlike drugs, where an increasing in dose means more disease and dependence, an increase in load (even if reduced) means more health, more strength and more vigor. This way, the daily decisions will always be up to each one: treat the body like a Ferrari or treat the body like a rental car.
- 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: 412–23.
- Cruz-Jentoft AJ, Bahat G, Bauer J, Boirie Y, Bruyère O, Cederholm T, Cooper C, Landi F, Rolland Y, Sayer AA, Schneider SM, Sieber CC, Topinkova E, Vandewoude M, Visser M, Zamboni M; Writing Group for the European Working Group on Sarcopenia in Older People 2 (EWGSOP2), and the Extended Group for EWGSOP2. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing. 2019 Jan 1;48(1):16-31.
- Bischoff-Ferrari HA, Orav JE, Kanis JA et al. Comparative performance of current definitions of sarcopenia against the prospective incidence of falls among community-dwelling seniors age 65 and older. Osteoporos Int 2015; 26:2793–802.
- Schaap LA, van Schoor NM, Lips P et al. Associations of sarcopenia definitions, and their components, with the incidence of recurrent falling and fractures: the longitudinal aging study Amsterdam. J Gerontol A Biol Sci Med Sci 2018; 73: 1199–204.
- Malmstrom TK, Miller DK, Simonsick EM et al. SARC-F: a symptom score to predict persons with sarcopenia at risk for poor functional outcomes. J Cachexia Sarcopenia Muscle 2016; 7: 28–36.
- Bahat G, Ilhan B. Sarcopenia and the cardiometabolic syndrome: a narrative review. Eur Geriatr Med 2016; 6: 220–23.
- Bone AE, Hepgul N, Kon S et al. Sarcopenia and frailty in chronic respiratory disease. Chron Respir Dis 2017; 14: 85–99.
- Chang KV, Hsu TH, Wu WT et al. Association between sarcopenia and cognitive impairment: a systematic review and metaanalysis. J Am Med Dir Assoc 2016; 17: 1164.e7–64.e15.
- Beaudart C, Biver E, Reginster JY et al. Validation of the SarQoL(R), a specific health-related quality of life questionnaire for Sarcopenia. J Cachexia Sarcopenia Muscle 2017; 8: 238–44.
- Dos Santos L, Cyrino ES, Antunes M et al. Sarcopenia and physical independence in older adults: the independent and synergic role of muscle mass and muscle function. J Cachexia Sarcopenia Muscle 2017; 8: 245–50.
- Akune T, Muraki S, Oka H et al. Incidence of certified need of care in the long-term care insurance system and its risk factors in the elderly of Japanese population-based cohorts: the ROAD study. Geriatr Gerontol Int 2014; 14: 695–701.
- Steffl M, Bohannon RW, Sontakova L et al. Relationship between sarcopenia and physical activity in older people: a systematic review and meta-analysis. Clin Interv Aging 2017; 12: 835–45.
- De Buyser SL, Petrovic M, Taes YE et al. Validation of the FNIH sarcopenia criteria and SOF frailty index as predictors of long-term mortality in ambulatory older men. Age Ageing 2016; 45: 602–8.
- Janssen I, Shepard DS, Katzmarzyk PT, Roubenoff R. The healthcare costs of sarcopenia in the United States. J Am Geriatr Soc. 2004 Jan;52(1):80-5.
- Sousa AS, Guerra RS, Fonseca I, Pichel F, Ferreira S, Amaral TF. Financial impact of sarcopenia on hospitalization costs. Eur J Clin Nutr. 2016 Sep;70(9):1046-51. doi: 10.1038/ejcn.2016.73. Epub 2016 May 11.
- Pinedo Villanueva, R. A., Westbury, L. D., Syddall, H. E., Sanchez, M., Dennison, E. M., Robinson, S. M., & Cooper, C. (2018). Health care costs associated with muscle weakness: a UK population-based estimate. Calcified Tissue International.
- Ruiz JR, Sui X, Lobelo F, et al. Association between muscular strength and mortality in men: prospective cohort study. BMJ. 2008;337(7661):a439. Published. doi:10.1136/bmj.a439.
- Srikanthan P, Karlamangla AS. Muscle mass index as a predictor of longevity in older adults. Am J Med. 2014;127(6):547-53.
- Dos Santos L, Cyrino ES, Antunes M, Santos DA, Sardinha LB. Changes in phase angle and body composition induced by resistance training in older women. Eur J Clin Nutr. 2016 Dec;70(12):1408-1413. doi: 10.1038/ejcn.2016.124. Epub 2016 Jul 13. PubMed PMID: 27406159.
- Cadore EL, Izquierdo M. Muscle Power Training: A Hallmark for Muscle Function Retaining in Frail Clinical Setting. J Am Med Dir Assoc. 2018 Mar;19(3):190-192.