Summary
Recently Renuka et al. [1] carried out a cross sectional pilot study that aimed to validate calf circumference as a reliable clinical tool for measuring muscle mass in Indian postmenopausal women. For this, thirty postmenopausal women were enrolled, excluding those with surgical menopause, premature ovarian failure, chronic debilitating illness and morbid obesity. Researchers compared muscle mass using calf circumference (CC) measurements with appendicular skeletal muscle index (ASMI), obtained via DEXA scans (considered the gold standard). The study highlights a 70% prevalence of sarcopenia in studied population. The better accuracy (80%) was found for the cut-off point of 32 cm for calf circumference. The sensitivity was 100%, specificity 60%, positive predictive value 71.4% and negative predictive value 100%. The investigators conclude that calf circumference can be used as reliable and practical clinical tool to assess sarcopenia as a measure of muscle mass in the studied Indian postmenopausal population.
Commentary
Sarcopenia is characterized by the gradual and generalized loss of skeletal muscle mass and not only strength but also function. It deeply impacts the healthcare expenditure and leads to adverse health consequences such as impaired quality of life and increased risk of morbidity and mortality [2]. To date, there is still no universal diagnostic criterion for the diagnosis of sarcopenia. The diagnostic classification was developed by the European Working Group on Sarcopenia in Older People (EWGSOP) and the Asian Working Group for Sarcopenia (AWGS) [3] which are the currently used.
Both EWGSOP and AWGS guidelines use the same measurements (i.e. muscle mass, muscle strength, and gait speed), but with different cut-off scores. However, there are differences in ethnicities, body size, lifestyles, and cultural background between European and Asian population [3] that need to be taken into consideration. The latest systematic review and meta-analyses reported that the global prevalence of sarcopenia varied between 10% and 27% [4]. Being Asia the fastest aging and most populated continent in the world; the impact of sarcopenia is considered to be stronger than in other continents. The newer term “possible sarcopenia” by AWGS in their latest guideline, refers to a condition of reduced muscle strength with or without reduction of physical performance [5]. This new terminology helps at the early identification of people with or at risk for sarcopenia in the primary healthcare or community preventive service settings, where advanced diagnostic equipment is not available. In addition, AWGS proposed calf circumference as a case finding tool for primary health care and community-based health promotion. They emphasized its simplicity and ease of measurement. In clinical settings, calf circumference values below a certain threshold (i.e. 32 cm) are considered as a potential indicator of low muscle mass. Recent studies have indicated that calf muscle circumference measured in a standing position has more accuracy than a sitting position [6].
With early identification, immediate lifestyle interventions (exercise, nutrition) can be given while patients wait for confirmatory diagnosis in the secondary or tertiary healthcare centers [7]. Studies like the commented here, collectively emphasize the importance of assessing muscle mass and addressing sarcopenia in high risk population. Health care professionals should stay informed, as such researches can guide clinical practice and enhance patient care.
Take home key points
- This study contributes valuable insights for the management of sarcopenia in communities with low resource settings, especially when more advanced imagining techniques (such as DEXA scans) are not available or feasible. Calf circumference serves as a surrogate indicator for muscle mass especially in older adults and postmenopausal women.
- Limitation of this study is small sample size; so further studies are warranted for robust cut-off points. Also, evaluating risk factors such as consideration of age, body mass index, vitamin D levels when interpreting calf circumference results is crucial.
- Clinicians can incorporate simple yet cost effective tools in assessing muscle health routinely during menopause to identify sarcopenia and tailor interventions accordingly.
As a health care provider let’s keep an eye on muscle health using a pragmatic approach of calf circumference measurements and empower our patients toward healthier aging!
Prof. Sunila Khandelwal, MS
Senior Consultant, Department of Obstetrics and Gynecology
Fortis Escorts Hospital
Jaipur, India
References
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- Renuka .S Assess Sarcopenia in Community Settings in Indian Postmenopausal Women. J Midlife Health. 2024;15(2):99-133.
https://journals.lww.com/jomh/fulltext/2024/15020/clinical_validation_of_calf_circumference_with.8.aspx - Cruz-Jentoft AJ, Sayer AA. Lancet. 2019;393(10191):2636-2646.
https://pubmed.ncbi.nlm.nih.gov/31171417/ - 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.
https://pubmed.ncbi.nlm.nih.gov/24461239/ - Petermann-Rocha F, Balntzi V, Gray SR, et al. Global prevalence of sarcopenia and severe sarcopenia: a systematic review and meta-analysis. J Cachexia Sarcopenia Muscle. 2022;13(1):86-99.
https://pubmed.ncbi.nlm.nih.gov/34816624/ - Chen LK, Woo J, Assantachai P, et al. Asian Working Group for Sarcopenia: 2019 Consensus Update on Sarcopenia Diagnosis and Treatment. J Am Med Dir Assoc. 2020;21(3):300-307.e2.
https://pubmed.ncbi.nlm.nih.gov/32033882/ - Rose Berlin Piodena-Aportadera M, Lau S, Chew J, et al. Calf Circumference Measurement Protocols for Sarcopenia Screening: Differences in Agreement, Convergent Validity and Diagnostic Performance. Ann Geriatr Med Res. 2022;26(3):215-224.
https://pubmed.ncbi.nlm.nih.gov/36031936/ - Kandinata SG, Widajanti N, Ichwani J, Firdausi H, Aryana IGPS, Alkaff FF. Diagnostic performance of calf circumference, SARC-F, and SARC-CalF for possible sarcopenia screening in Indonesia. Sci Rep. 2023;13(1):9824.
https://pubmed.ncbi.nlm.nih.gov/37330539/
- Renuka .S Assess Sarcopenia in Community Settings in Indian Postmenopausal Women. J Midlife Health. 2024;15(2):99-133.
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