Application of Selected Muscle Strength and Body Mass Cut Points for the Diagnosis of Sarcopenia in Men and Women With or at Risk for HIV Infection

Prognostic Value of Sarcopenia Definitions and Outcomes Consortium Criteria in Older Patients with Heart Failure

OBJECTIVES

The Asian Working Group for Sarcopenia in 2019 (AWGS 2019) emphasized muscle mass measurements. In contrast, the Sarcopenia Definitions and Outcomes Consortium (SDOC) prioritizes functional strength and mobility. Therefore, this study aimed to compare the prognostic utility of the SDOC and AWGS 2019 criteria for all-cause mortality in older patients with heart failure.

DESIGN

A post hoc analysis of the Prevalence and Prognostic Value of Physical and Social Frailty in Geriatric Patients Hospitalized for Heart Failure (FRAGILE-HF) study, a prospective, multicenter, observational study.

SETTING AND PARTICIPANTS

Patients aged ≥65 years hospitalized for heart failure across 15 hospitals in Japan.

METHODS

Sarcopenia was diagnosed according to the AWGS 2019 and SDOC definitions. According to the SDOC criteria and by integrating insights from previous research, patients were categorized into nonsarcopenia, possible sarcopenia, and sarcopenia groups. The primary outcome was 2-year mortality.

RESULTS

Of the 1282 study patients, possible sarcopenia and sarcopenia were diagnosed in 357 and 786 individuals, respectively. Kaplan-Meier analysis revealed a significant difference between the groups. Adjusted Cox proportional hazards analysis indicated a significant stepwise association between sarcopenic status and mortality risk (possible sarcopenia: hazard ratio, 1.22; 95% CI, 0.66-2.28; P = .525; sarcopenia: hazard ratio, 1.89; 95% CI, 1.08-3.34; P = .027). When sarcopenia defined by the SDOC and AWGS 2019 criteria was added to the model incorporating conventional risk factors, no significant difference was observed in the prognostic capabilities between the 2 models (net reclassification improvement, -0.009; 95% CI, -0.193 to 0.174; P = .920, with areas under the receiver operating characteristic curve of 0.697 for SDOC and 0.703 for AWGS 2019; P = .675).

CONCLUSIONS AND IMPLICATIONS

Among older patients with heart failure, the SDOC criteria for sarcopenia diagnosis are useful for risk stratification and provide prognostic capabilities equivalent to those of the AWGS 2019 criteria.

Sex Differences in Metabolic Disorders of Aging and Obesity in People with HIV

PURPOSE OF REVIEW

As advances in antiretroviral therapy for people with HIV (PWH) have prolonged lifespans, prevalence of aging and obesity related metabolic disorders have increased. The purpose of this review is to summarize recent research assessing sex differences in metabolic disorders among PWH, including weight gain/obesity, steatotic liver disease, insulin resistance/diabetes, dyslipidemia, bone loss/osteoporosis, and sarcopenia.

RECENT FINDINGS

A growing body of evidence shows that women with HIV are at increased risk of developing metabolic disorders compared to men, including body weight gain and obesity, type 2 diabetes mellitus, dyslipidemia, bone loss, and sarcopenia, while men with HIV are at higher risk for hepatosteatosis and hepatic fibrosis. Future work should prioritize the adequate representation of women in HIV clinical studies. Understanding sex-specific mechanisms underlying metabolic dysfunction in PWH is imperative so that interventions can be developed to address a growing global epidemic of metabolic diseases.

The use of non-invasive imaging modalities for the assessment of skeletal muscle quantity and quality in people with HIV: A narrative review

BACKGROUND

People with HIV (PWH) are prone to mobility impairments and physical dysfunction, with the loss of skeletal muscle quantity and quality being a major contributor to the dysfunction. Assessment of skeletal muscle is an important component of care for this patient population for early intervention and treatment. The use of non-invasive imaging techniques to evaluate skeletal muscle, such as dual X-ray absorptiometry, computer tomography and magnetic resonance imaging, has increased in popularity in recent years.

PURPOSE

This narrative review synthesizes the use of these techniques and summarizes the associations between outcomes from these imaging modalities and physical function in PWH.

Associations of Muscle Density and Area With Coronary Artery Plaque and Physical Function

OBJECTIVE

Skeletal muscle quality and mass are important for maintaining physical function during advancing age. We leveraged baseline data from Randomized Trial to Prevent Vascular Events in HIV (REPRIEVE) to evaluate whether paraspinal muscle density and muscle area are associated with cardiac or physical function outcomes in people with HIV (PWH).

METHODS

REPRIEVE is a double-blind randomized trial evaluating the effect of pitavastatin for primary prevention of major adverse cardiovascular events in PWH. This cross-sectional analysis focuses on participants who underwent coronary computed tomography at baseline. Lower thoracic paraspinal muscle density (Hounsfield units [HU]) and area (cm 2 ) were assessed on noncontrast computed tomography.

RESULTS

Of 805 PWH, 708 had paraspinal muscle measurements. The median age was 51 years and 17% were natal female patients. The median muscle density was 41 HU (male) and 30 HU (female); area 13.2 cm 2 /m (male) and 9.9 cm 2 /m (female). In adjusted analyses, greater density (less fat) was associated with a lower prevalence of any coronary artery plaque, coronary artery calcium score >0, and high plaque burden ( P = 0.06); area was not associated with plaque measures. Among 139 patients with physical function measures, greater area (but not density) was associated with better performance on a short physical performance battery and grip strength.

CONCLUSIONS

Among PWH, greater paraspinal muscle density was associated with a lower prevalence of coronary artery disease while greater area was associated with better physical performance. Whether changes in density or area are associated with changes in CAD or physical performance will be evaluated through longitudinal analyses in REPRIEVE.

A systematic review of sarcopenia prevalence and associated factors in people living with human immunodeficiency virus

People living with human immunodeficiency virus (HIV) (PLWH) appear to be at an increased risk of sarcopenia, which can have a devastating effect on their life due to consequences such as physical disability, poor quality of life, and finally death. This systematic review examined sarcopenia prevalence and its associated factors in PLWH. A systematic search was conducted using the keywords in the online databases including Scopus, PubMed, Web of Science, Embase and Cochrane databases from the dates of inception up to May 2022. The retrieved articles underwent a two-step title/abstract and full-text review process, and the eligible papers were selected and included in the qualitative synthesis. Data relating to the study population, purpose of study, gender, age, race, body mass index, medical history, paraclinical results and antiretroviral therapy as associated factors of sarcopenia were extracted. In addition, the prevalence of sarcopenia in PLWH and its promoting and reducing factors were also extracted. We reviewed the 14 related studies for identifying of sarcopenia prevalence and its associated factors in PLWH. The total number of PLWH in all the reviewed studies was 2592. There was no criterion for the minimum number of people with HIV and the lowest number of PLWH was 27, and the highest number was 860. Some studies reported a significantly higher prevalence of sarcopenia in HIV-infected individuals compared with HIV-negative controls as follows: 24.2-6.7%, 15-4% and 10-6%, respectively. We showed that, age (30-50 years), being female, >5 years post-HIV diagnosis, multiple vertebral fractures, cocaine/heroin use and lower gamma-glutamyl transferase level were the main promoting factors of sarcopenia. Higher educational level, employment, physical exercise, calf circumference >31 cm, and gait speed >0.8 m/s were also factors to reduce sarcopenia. Sarcopenia prevalence in PLWH is higher than HIV-negative population. Given the importance and prevalence of sarcopenia among PLWH and its associated consequences (i.e., mortality and disability), determining its risk factors is of great importance.

Appendicular Skeletal Muscle Mass Prediction in People Living With HIV: A Cross-Sectional Study

ABSTRACT

People living with HIV (PWH) experience an accelerated aging process. There is no anthropometric predictive model for appendicular skeletal muscle mass (ASM) in PWH. This study develops anthropometric models to predict and validate ASM measured by dual energy x-ray absorptiometry (DXA) in PWH; DXA scans were obtained for 125 PWH (male = 74; age >18 years) on antiretroviral therapy. Fat mass ratio was used for lipodystrophy diagnosis. A multiple stepwise linear regression considered ASMDXA as the dependent variable and validated by PRESS method. A high power of determination and low standard estimate error were found for ASMDXA-predicted (adjusted r2 = 0.84 to 0.87, standard estimate error = 1.7-1.6 kg) and high PRESS validation coefficients (Q2PRESS = 0.84-0.86, SPRESS = 1.7-1.6 kg). The variables included were lipodystrophy diagnosis, medial calf circumference, sex, and total body weight. We present novel, reliable, and validated anthropometric models to predict ASMDXA in PWH.

Relationship Between Handgrip Strength and Age in the Body Composition Variables Among People Living with HIV

BACKGROUND

The study of aging and handgrip strength (HGS) is important to gain knowledge regarding health care and quality of life in people living with HIV (PLHIV).

OBJECTIVE

The aim of the study is to analyze the relationship between HGS and age in the body composition variables of PLHIV.

METHODS

The sample consisted of 77 PLHIV, divided into three groups: G40 - PLHIV aged 40-49 years (n=39); G50 - PLHIV aged 50-59 years (n=26); and G60 - PLHIV aged 60-69 years (n=12). Data collection included anamnesis (sociodemographic, clinical, and laboratory information), physical assessment (body composition and HGS), and physical activity level. Data were analyzed by descriptive and inferential statistics.

RESULTS

It was noted that men, compared to women, are 5.85 times more likely to present adequate HGS (p<0.001). In addition, adequate HGS was associated with adequate values of body mass index (p<0.001), waist circumference (p<0.001), and fat percentage (p<0.001). The G40 and G50 groups, in relation to the G60, were associated with adequate abdominal circumference (p=0.04).

CONCLUSION

Monitoring the evolution of HGS in PLHIV, over time, makes it possible to infer about body fat and muscle mass, in order to propose prevention actions and guidelines to prevent early muscle loss, the development of overweight/obesity, and abdominal obesity.

Cardiovascular risk score associations with frailty in men and women with or at risk for HIV

OBJECTIVE

To understand the relationship between cardiovascular disease (CVD) risk and frailty among men (MWH) and women living with HIV (WWH), or at risk for HIV.

DESIGN

We considered 10-year coronary heart disease and atherosclerotic CVD risk by Framingham risk score (FRS, 2001 National Cholesterol Education Program Adult Treatment Program III) and Pooled Cohort Equations (PCE, 2013 American College of Cardiology/American Heart Association) in relation to the Fried Frailty Phenotype (FFP) in the Multicenter AIDS Cohort Study (MACS) and Women's Interagency HIV Study (WIHS).

METHODS

FFP was ascertained in MACS from 2004 to 2019 and in WIHS from 2005 to 2006 and 2011-2019. FFP score at least three of five components defined frailty. Repeated measures logistic regression (both cohorts) and Cox proportional hazards regression (MACS) were performed, controlled for education, income, cholesterol medication and hepatitis C virus serostatus, and among MWH and WWH, CD4+ cell count/μl, antiretroviral therapy, and HIV viral load.

RESULTS

There were 5554 participants (1265 HIV seronegative/1396 MWH; 768 seronegative/1924 WWH) included. Among men, high-risk FRS was associated with increased risk of incident frailty among seronegative [adjusted hazard ratio (aHR)) = 2.12, 95% confidence interval (CI):1.22-3.69] and MWH (aHR = 2.19, 95% CI: 1.33-3.61). Similar associations were seen with high-risk PCE and incident frailty among SN (aHR = 1.88, 95% CI: 1.48-2.39) and MWH (aHR = 1.59, 95% CI: 1.26-2.00). Among women, high-risk PCE was associated with frailty in SN [adjusted odds ratio (aOR) = 1.43, 95% CI: 1.02-2.00] and WWH (aOR = 1.36, 95% CI: 1.08-1.71); however, high-risk FRS was not (seronegative: aOR = 1.03, 95% CI: 0.30-3.49; WWH: aOR = 0.86, 95% CI: 0.23-3.20).

CONCLUSION

Higher CVD risk was associated with increased frailty regardless of HIV serostatus among men and women. These findings may inform clinical practices of screening for frailty.

Differences in Muscle Quantity and Quality by HIV Serostatus and Sex

OBJECTIVE

People with HIV (PWH) experience greater declines in both muscle function and muscle mass with aging. Whether changes in muscle quality and quantity with aging differ between men and women with HIV and the implications on muscle function are not established.

DESIGN

In coordinated substudies of the Multicenter AIDS Cohort Study and Women's Interagency HIV Study, participants completed physical function and falls assessments; total trunk/thigh density, inversely related to fatty infiltration, and area were quantified from computed tomography (CT) scans.

METHODS

Generalized linear models were used to explore variables affecting density/area, and associations between area/density and physical function and falls.

RESULTS

CT scans were available on 387 men (198 PWH) and 184 women (118 PWH). HIV serostatus was associated with greater lateralis, paraspinal, and hamstring area, but lower psoas area and density. Older age and female sex were associated with smaller trunk muscle area and lower density. Both lower muscle area and muscle density were associated with several measures of impaired physical function. The odds of falling were lower with greater hamstring density, but not associated with other measurers of muscle area or density.

CONCLUSIONS

In summary, older adults with HIV appear to have smaller and less dense (fattier) psoas, a key component in truncal stability and hip flexion that could have implications on physical function. The longitudinal associations of muscle area and density with physical function require careful investigation, with a particular focus on characteristics and interventions that can preserve muscle area, density, and function over time.

People Living With HIV, Lean Mass, and Sarcopenia: A Systematic Review and Meta-Analysis

This systematic review aims to estimate the prevalence of sarcopenia in people living with HIV (PLHIV) and to assess whether there is a difference between the muscle mass of PLHIV and people living without HIV. A systematic review of randomized controlled trials, cohort studies, cross-sectional and case-control studies was carried out. PLHIV over 18 years of age and that had their muscle mass evaluated by dual-energy X-ray absorptiometry were included. Overall, 4,376 studies were found, of which 118 had their full texts evaluated. A total of 5,532 people living with HIV and 2,986 people living without HIV were identified in 41 studies. The frequency of sarcopenia defined by low muscle mass (Baumgartner's operational definition) alone was 30.3% (95%CI 24.3%, 37.1%) and the frequency of sarcopenia defined by low muscle mass with low muscle strength (EWGSOP definition) was 4.5% (95%CI 1.3%, 13.9%), p-value = 0.0006. The standardized mean differences of muscle mass between PLHIV and controls was -0.211 units of standard deviation (95%CI -0.419, -0.003). In the meta-regression analysis muscle mass mean difference was associated with BMI, CD4, percentage of subjects on ART, and study design. PLHIV have a lower muscle mass when compared to people living without HIV. This difference appears to be attenuated by higher BMI, CD4 levels, and the percentage of subjects using ART. Furthermore, the frequencies of sarcopenia assessed by the operational definition of Baumgartner and the EWGSOP are not comparable and cannot be interchanged in PLHIV.

Poorer Muscle Quality and Quantity With ART Initiation Is Associated With Greater Inflammation and Immune Activation

BACKGROUND

We have previously shown that the initiation of antiretroviral therapy (ART) is associated with a decrease in skeletal muscle density (greater fat accumulation), suggesting that gains in lean body mass seen in many ART studies may reflect gains in low quality, fatty muscle. Here, we explore whether skeletal muscle density and area are associated with markers of inflammation and immune activation.

METHODS

ART-naïve people with HIV were randomized to raltegravir or ritonavir-boosted atazanavir or darunavir, each with tenofovir disoproxil fumarate/emtricitabine. Abdominal computed tomography scans from baseline and week 96 were reanalyzed for psoas density and area and correlations explored with inflammation [interleukin-6 (IL-6) and high-sensitivity C-reactive protein] and immune activation [soluble CD14 (sCD14), soluble CD163 (sCD163), and %CD38+HLADR+ on CD4+ or CD8+ T cells].

RESULTS

Two hundred twenty-two participants had available inflammation/immune activation markers and paired computed tomography scans. At baseline, lower psoas density (greater fat) correlated with higher IL-6 (r = -0.26, P < 0.001) and sCD163 (r -0.15, P = 0.03) and lower lean psoas area correlated with higher IL-6, high-sensitivity C-reactive protein, sCD14, sCD163, and %CD38+HLADR+ on CD4+ T cells (r = -0.30-0.13; all P ≤ 0.05). From baseline to week 96, greater percent decrease in total psoas density (more fat) correlated with greater increase in IL-6 (r = -0.14; P = 0.04); greater % decrease in lean psoas area correlated greater increases in IL-6, sCD14, sCD163, and %CD38+HLADR+ on CD8+ T cells (r = -0.15 to -0.18; all P < 0.04).

CONCLUSIONS

Greater fat infiltration within the psoas muscle (lower density) and greater loss in lean psoas muscle area were associated with higher inflammation and immune activation, which may portend important effects on muscle function and cardiometabolic risk.

Low Agreement Between Initial and Revised European Consensus on Definition and Diagnosis of Sarcopenia Applied to People Living With HIV

BACKGROUND

In 2019, the European Working Group on Sarcopenia in Older People (EWGSOP2) proposed low muscle strength as the primary outcome for sarcopenia diagnosis instead of low muscle mass, as proposed in 2010 (EWGSOP1). Therefore, the aim of this study was to compare the prevalence of sarcopenia using both EWGSOP1 and EWGSOP2 operational definitions in people living with HIV (PLHIV) and to determine the agreement and correlation between different tests proposed by EWGSOP2.

SETTING

Cross-sectional study, where 302 PLHIV (151 men), 51.7 ± 9.0 years old were evaluated for the presence of sarcopenia using both EWGSOP1 and EWGSOP2 operational definitions.

METHODS

Appendicular skeletal muscle was estimated using bioimpedance analysis. Handgrip strength, chair stand, gait speed, and static balance were used as muscle function measures. Agreement was determined using Cohen kappa and Pearson correlation coefficient was calculated.

RESULTS

Sarcopenia prevalence was 4.3% using EWGSOP1 and 1.0% using EWGSOP2. Agreement for sarcopenia diagnosis between EWGSOP1 and EWGSOP2 was fair (k = 0.37, P < 0.01). From the 13 cases of sarcopenia diagnosed using EWGSOP1, only 3 cases (23.1%) were also diagnosed using EWGSOP2. A medium correlation (r = -0.32, P < 0.01) and poor agreement (k = 0.14, P < 0.01) between muscle strength tests (handgrip strength and chair stand) were observed. Concordance between handgrip and chair stand was observed in 11 participants only, whereas 65 participants were considered to have low muscle strength using chair stand but not using handgrip.

CONCLUSIONS

Lower sarcopenia prevalence using EWGSOP2 and low agreement between EWGSOP1 and EWGSOP2 operational definitions in diagnosing sarcopenia were observed in PLHIV.

Putative Cut-Points in Sarcopenia Components and Incident Adverse Health Outcomes: An SDOC Analysis

OBJECTIVES

Analyses performed by the Sarcopenia Definitions and Outcomes Consortium (SDOC) identified cut-points in several metrics of grip strength for consideration in a definition of sarcopenia. We describe the associations between the SDOC-identified metrics of low grip strength (absolute or standardized to body size/composition); low dual-energy x-ray absorptiometry (DXA) lean mass as previously defined in the literature (appendicular lean mass [ALM]/ht2 ); and slowness (walking speed <.8 m/s) with subsequent adverse outcomes (falls, hip fractures, mobility limitation, and mortality).

DESIGN

Individual-level, sex-stratified pooled analysis. We calculated odds ratios (ORs) or hazard ratios (HRs) for incident falls, mobility limitation, hip fractures, and mortality. Follow-up time ranged from 1 year for falls to 8.8 ± 2.3 years for mortality.

SETTING

Eight prospective observational cohort studies.

PARTICIPANTS

A total of 13,421 community-dwelling men and 4,828 community-dwelling women. MEASUREMENTS Grip strength by hand dynamometry, gait speed, and lean mass by DXA.

RESULTS

Low grip strength (absolute or standardized to body size/composition) was associated with incident outcomes, usually independently of slowness, in both men and women. ORs and HRs generally ranged from 1.2 to 3.0 for those below vs above the cut-point. DXA lean mass was not consistently associated with these outcomes. When considered together, those who had both muscle weakness by absolute grip strength (<35.5 kg in men and <20 kg in women) and slowness were consistently more likely to have a fall, hip fracture, mobility limitation, or die than those without either slowness or muscle weakness.

CONCLUSION

Older men and women with both muscle weakness and slowness have a higher likelihood of adverse health outcomes. These results support the inclusion of grip strength and walking speed as components in a summary definition of sarcopenia. J Am Geriatr Soc 68:1429-1437, 2020.

Application of Cut-Points for Low Muscle Strength and Lean Mass in Mobility-Limited Older Adults

BACKGROUND

The Sarcopenia Definitions and Outcomes Consortium (SDOC) is a collaborative initiative seeking to develop and evaluate cut-points for low muscle strength and lean mass that predict an increased risk for slowness (usual walking speed <.8 m/s) among older adults.

OBJECTIVES

The goal of the present study was to provide clinicians and researchers with an understanding of the diagnostic implications of using SDOC variables and cut-points in mobility-limited older adults. Using data from older individuals with specific conditions that render them at increased risk for mobility limitation, we evaluated the performance characteristics (ie, sensitivity and specificity) of five putative sarcopenia parameters and then compared these values with previously recommended diagnostic criteria for sarcopenia.

DESIGN

Retrospective analysis of six randomized controlled trials enriched in persons at risk for mobility limitation.

SETTING

National and international geriatric clinical research centers.

PARTICIPANTS

A total of 925 mobility-limited older adults (≥55 years of age; 58% women) were included in the analysis.

MEASUREMENTS

The prevalence of low muscle strength and lean mass were assessed using five candidate metrics discriminative of slowness. Analyses of sensitivity and specificity were used to compare muscle weakness criteria with published diagnostics for sarcopenia.

RESULTS

Odds ratios (ORs) supported maximal grip strength (Grip max <35.5 and 20.0 in men and women, respectively) as the most discriminative of slowness in both men and women (OR = 3.66 and 3.53, respectively). More men (58%) than women (30%) fell below sex-specific maximal grip cut-points. When applying previously recommended sarcopenia component definitions in our population, we found that fewer individuals met those criteria (range = 6%-32%).

CONCLUSION

A greater number of individuals fall below SDOC Grip max cut-points compared with previous recommendations. Clinicians and researchers working with older adults may consider these thresholds as an inclusive means to identify candidates for low-risk lifestyle promyogenic and function-promoting therapies. J Am Geriatr Soc 68:1445-1453, 2020.