Osteosarcopenia Detection and Treatment

Tony Clark, CSO and Steve Fratini, PhD:  December 2, 2024

Introduction

Osteosarcopenia induced frailty can initiate a descending health spiral comprising muscle loss, which leads to less activity, and which, in-turn, can contribute to bone loss, declining health, increased risk of falls, fractured bones, and in some instances death—see Figure 1.  A significant risk factor for Osteosarcopenia induced frailty is the chronic underconsumption of IAAs [3]. 

Eating enough IAAs is critical for the maintenance and growth of both bones and muscles.  However, 2-Dooz Research Labs has found that the average consumption of IAAs by older adults appears to be inadequate.  Per Figure 2, both men and women, 56 years old and older, fail to consume IAAs at a rate that is sufficient to protect against Osteosarcopenia caused frailty [4] [5] [6].  Seven out of the nine IAAs are consumed at levels that are less than 60% of the assumed daily amount needed to help forestall physical frailty.  Therefore, a sound plan to defy Osteosarcopenia induced frailty should include the increased consumption of each IAA*.  This assessment is consistent with 2-Dooz Research Labs’ previous findings for how the typical American diet compares to the Protein and IAA ADRI.

By the Numbers

One third of all seniors fall at least once per year, and falls are the leading cause of injury among older adults [7], comprising more than 14 million annual falls within the U.S. alone [8].  Moreover, nearly 50,000 seniors die after falling each year [9].  Falls lead to 3 million emergency department visits each year and are the most common cause of traumatic brain injuries [11].

Osteoporosis, a component of Osteosarcopenia, is a systemic skeletal disorder characterized by low bone mass (a result of the micro-architectural deterioration of bone tissue leading to more porous bone) and characterized by a consequent increased risk of fracture.  In adults aged 50 years and over, 12.6% had osteoporosis of the hip, spine, or both, according to 2016-17 data from the Centers for Disease Control and Prevention (CDC).  Among females, the prevalence was 19.6%, compared with 4.4% of males [10].

Sarcopenia, also a component of Osteosarcopenia, is a type of muscle loss that occurs with aging and/or immobility.  It is characterized by the degenerative loss of skeletal muscle mass, quality, and strength.  Sarcopenia leads to an increased risk of falls [12].  Up to 37% of community-dwelling older adults are estimated to have Sarcopenia [7].

Osteosarcopenia and Frailty

Frailty is the consequence of a combination of mobility and other systemic health issues, see Figure 3 below.  Osteosarcopenia is the principal factor regarding the mobility aspect of frailty.  The combination of factors has devastating effects on one’s health—negatively impacting quality of life and precipitating or enhancing chronic disease [20].  Once in the downward health spiral, it is very difficult to reverse the direction.  Thus, early detection and prevention are critical to combating frailty. 

Detection

There are no screening or risk calculation tools validated for Osteosarcopenia.  However, numerous tools are available at the clinician’s disposal for the two major components of Osteosarcopenia: osteoporosis and sarcopenia [18].

Osteoporosis is known as a “silent disease" since it often has no symptoms.  In many cases, osteoporosis has been progressing for years, and is only diagnosed when a person breaks a bone.  However, there are some warning signs that could indicate one is on the path to osteoporosis (or already there), e.g., loss of height, bone fractures from mild trauma, a curved upper back, and sudden back pain [16] may signal the early stages of osteoporosis.

A bone density test may initially be used to determine if a patient has osteoporosis or the lesser aliment of osteopenia.  The test uses low energy X-rays to measure how much calcium and other bone minerals are packed into a segment of bone.  Generally, the spine, hip or forearm is tested.  To confirm that one has (or does not have) osteoporosis, a dual-energy X-ray absorptiometry (DEXA) scan is required.  

For sarcopenia, the most significant sign is the loss of lean muscle mass, or muscle atrophy; though a change in body composition may be difficult to detect due to obesity, changes in fat mass, or edema.  Moreover, changes in weight, limb or waist circumference are not reliable indicators of muscle mass changes.  Consequently, sarcopenia may appear symptomless until it has advanced to a severe state. 

Research has revealed a promising detection method for sarcopenia: muscle hypertrophy (i.e., muscle growth) in the upper parts of the body, which compensates for the loss of lean muscle mass elsewhere, may indicate the presence of the condition [13].  For example, a significant loss of muscle mass in the anterior thigh and abdominal muscles, accompanied by a gain of muscle in the upper body, may be an early indication of the onset of sarcopenia.  

In addition, the following at-home tests per the NIH National Library of Medicine [14] can be performed if sarcopenia is suspected.

• Handgrip test: Generally, handgrip strength is one of the two methods utilized to quantify muscle strength in patients with suspected sarcopenia.  Handgrip strength correlates with strength in other muscles and is therefore used as a surrogate to detect deficits in overall strength.  For the test, one needs a handgrip dynamometer (an inexpensive device that can be purchased online).  The cutoff point for handgrip strength is <27 kg for males and <16 kg for females.

• Chair stand test: The chair stand test may be used as a proxy to gauge lower extremity strength, particularly the quadriceps muscles.  The chair stand test measures the number of times a patient can stand and sit from a chair, without the use of their arms.  Taking more than 15 seconds to perform a set of 5 unassisted rises may indicate sarcopenia.

• Gait speed test: Gait speed tests are simple to use in practice and predict adverse effects associated with sarcopenia. The "4-meter usual walking speed test" is practical and can be used to assess sarcopenia severity.  In this test, one measures the time taken for a patient to travel 4 meters at their usual walking pace.  A speed of less than 0.8 meters per second (i.e., more than 3.2 seconds to cover 4 meters or about 13 feet) may be indicative of severe sarcopenia.

Inclusive of the aforementioned tests, scanning provides the most accurate method to confirm a sarcopenia diagnosis.  As is the case for detecting osteoporosis, the DEXA scan is considered the gold standard for definitively detecting sarcopenia [15]. 

Defiance

Defying Osteosarcopenia induced frailty essentially boils down to taking steps to prevent it, as osteoporosis is only minimally reversible via medication, a nutrient-dense diet and weight bearing exercise (e.g., walking and weight lifting).  This currently leaves prevention of Osteosarcopenia as the only way to reliably forestall frailty in elderly adults.

For those who wish to avoid drugs, and their possible side effects, for the treatment of frailty, prevention may comprise the following:

• Sufficient intake of calcium and Vitamin D;

• Frequent strength building exercise [19]; and

• Adequate consumption of IAAs [20].

Regarding the sarcopenia aspect of Osteosarcopenia, a randomized, double-blind, and placebo-controlled supplementation trial [17] concluded that supplementation with whey protein, essential amino acids, and vitamin D, in conjunction with age-appropriate exercise, increased muscle mass, increased strength and enhanced other aspects that contribute to well-being in elderly sarcopenic sufferers.  Study participants generally experienced improved handgrip strength.

Regarding Osteosarcopenia, randomized controlled trials (RCTs) have demonstrated the efficacy of progressive resistance exercise to stimulate osteoblastogenesis (i.e., bone formation) and muscle protein synthesis, leading to improvements in bone microarchitecture, muscle mass, strength, and functional capacity in osteoporotic and sarcopenic older adults [18].   RCTs have additionally examined the effect of protein supplementation in conjunction with resistance exercise interventions and demonstrated augmentations in muscle and bone mass, as well as muscle strength, balance, and functional capacity [18].  Again, a more proactive approach to frailty entails preventing the onset of osteoporosis with proper nutrient intake and exercise.  Further, prevention allows one to avoid the osteoporosis medications and their associated side effects.

Adequate IAAs consumption takes into account that a typical older adult has multiple health diminishing factors (see Figure 3), inclusive of a reduced capacity for muscle protein synthesis.  Adequate IAAs consumption is assumed to be approximately 2.5 times the IAA ADRI.  Readers should consult their personal doctor and/or nutritionist for a protocol that is customized for their unique needs.

The story is not as rosy for the average U.S. senior.  Figure 2 and Figure 4, per 2-Dooz Research Labs’ IAAs findings for an average U.S. man and woman who is 56 years old or older, show a significant deficiency in the consumption of all IAAs relative to the 2-Dooz Research Labs assumed optimal reference amounts, which are presumed necessary to defy frailty—2.5x the IAA ADRI.  Leucine and tryptophan consumption fell the most below the assumed optimal amounts, at under 40% of their respective recommended amount.  Note that an overview of the methodology used by 2-Dooz Research Labs to estimate the daily average IAA consumption by US women and men can be found here.   The apparent inadequate IAAs consumption by U.S. seniors may place them at a higher risk for the development of Osteosarcopenia.

Conclusion

2-Dooz Research Lab's findings regarding reported daily IAAs consumption habits suggest that the average older man and woman in the U.S. appear to be at risk for becoming frail.  Fortunately, prevention is a viable means to defy, or forestall progression to Osteosarcopenia induced frailty and its associated health diminishing outcomes.  An effective prevention protocol requires consuming more IAAs along with the performance of strength building exercise, 3 to 5 times per week, and the sufficient intake of vitamin D and calcium.  Complying with such a protocol has been clinically demonstrated to be protective against Osteosarcopenia induced frailty.

References

[1]         Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web–based Injury Statistics Query and Reporting System (WISQARS), https://wisqars.cdc.gov/, accessed on 30 June 2024.

[2]        Centers for Disease and Control, Older Adults Falls Data. https://www.cdc.gov/falls/data-research/index.html#cdcreference_5, 09 May 2024, Accessed 26 June 2024.

[3]        Coelho-Junior HJ, Calvani R, Azzolino D, Picca A, Tosato M, Landi F, Cesari M, Marzetti E. Protein Intake and Sarcopenia in Older Adults: A Systematic Review and Meta-Analysis. Int J Environ Res Public Health. 2022 Jul 18;19(14):8718. doi: 10.3390/ijerph19148718. PMID: 35886571; PMCID: PMC9320473.

[4]   R. P. Heaney, Protein and calcium: antagonists or synergists?  The American Journal of Clinical Nutrition, vol. 75, pp. 609-610, 2002.

[5]        Delmi M, Rapin CH, Bengoa JM, Delmas PD, Vasey H, Bonjour JP., Dietary supplementation in elderly patients with fractured neck of the femur. Lancet 1990;335:1013–6.

[6]   [Schürch MA, Rizzoli R, Slosman D, Vadas L, Vergnaud P, Bonjour JP., Protein supplements increase serum insulin-like growth factor levels and attenuate proximal femur bone loss in patients with recent hip fracture. Ann Intern Med 1998;128:801–9.

[7]        Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web–based Injury Statistics Query and Reporting System (WISQARS), https://wisqars.cdc.gov/, accessed on 30 June 2024.

[8]       Kakara R, Bergen G, Burns E, Stevens M., Nonfatal and Fatal Falls Among Adults Aged ≥65 Years - United States, 2020–2021. MMWR Morbidity and Mortality Weekly Report. 2023;72:938–943. DOI: 10.15585/mmwr.mm7235a1.

[9]       Centers for Disease and Control, Older Adults Falls Data. https://www.cdc.gov/falls/data-research/index.html#cdcreference_5, 09 May 2024, Accessed 26 June 2024.

[10]    Sherrell, Z, How common is osteoporosis, Medical News Today, https://www.medicalnewstoday.com/articles/how-common-is-osteoporosis, accessed on 22 July 2024.

[11]      Center for Disease Control and Prevention, Older Adult Fall Prevention. https://www.cdc.gov/falls/data-research/facts-stats/index.html#cdcreference_2, May 9, 2024, Accessed August 8, 2024.

[12]     Yeung, S.S.Y., et al., Sarcopenia and its association with falls and fractures in older adults: A systematic review and meta-analysis.   J Cachexia Sarcopenia Muscle. 2019 Jun; 10(3): 485–500.  Published online 2019 Apr 16.

[13] Özkal Ö, Kara M, Topuz S, Kaymak B, Bakı A, Özçakar L. Assessment of core and lower limb muscles for static/dynamic balance in the older people: An ultrasonographic study. Age Ageing. 2019 Nov 1;48(6):881-887. doi: 10.1093/ageing/afz079. PMID: 31268513.

[14]    NIH National Library of Medicine, Sarcopenia, summary article, https://www.ncbi.nlm.nih.gov/books/NBK560813/, accessed on 24 June 2024. von

[15] Haehling S, Morley JE, Anker SD. An overview of sarcopenia: facts and numbers on prevalence and clinical impact. J Cachexia Sarcopenia Muscle. 2010 Dec;1(2):129-133. doi: 10.1007/s13539-010-0014-2. Epub 2010 Dec 17. PMID: 21475695; PMCID: PMC3060646.

[16]    Bence, S., 9 Early Warning Signs of Osteoporosis, Very Well Health, https://www.verywellhealth.com/early-warning-signs-of-osteoporosis-6828360, accessed on 28 August 2024.

[17] Rondanelli M, Klersy C, Terracol G, Talluri J, Maugeri R, Guido D, Faliva MA, Solerte BS, Fioravanti M, Lukaski H, Perna S. Whey protein, amino acids, and vitamin D supplementation with physical activity increases fat-free mass and strength, functionality, and quality of life and decreases inflammation in sarcopenic elderly. Am J Clin Nutr. 2016 Mar;103(3):830-40. doi: 10.3945/ajcn.115.113357. Epub 2016 Feb 10. PMID: 26864356.

[18]    Kirk B, Zanker J, Duque G. Osteosarcopenia: epidemiology, diagnosis, and treatment-facts and numbers. J Cachexia Sarcopenia Muscle. 2020 Jun;11(3):609-618. doi: 10.1002/jcsm.12567. Epub 2020 Mar 22. PMID: 32202056; PMCID: PMC7296259.

[19]    Bloch-Ibenfeldt M, et al., Heavy resistance training at retirement age induces 4-year lasting beneficial effects in muscle strength: a long-term follow-up of an RCT. BMJ Open Sp Ex Med 2024;10:e001899. doi:10.1136/bmjsem-2024-001899. https://bmjopensem.bmj.com/content/bmjosem/10/2/e001899.full.pdf.

[20]   Wolfe RR., The role of dietary protein in optimizing muscle mass, function and health outcomes in older individuals. British Journal of Nutrition. 2012;108(S2):S88-S93. doi:10.1017/S0007114512002590.