Abstract
The prevalence of obesity in combination with sarcopenia (the age-related loss of muscle mass and strength or physical function) is increasing in adults aged 65 years and older. A major subset of adults over the age of 65 is now classified as having sarcopenic obesity, a high-risk geriatric syndrome predominantly observed in an ageing population that is at risk of synergistic complications from both sarcopenia and obesity. This Review discusses pathways and mechanisms leading to muscle impairment in older adults with obesity. We explore sex-specific hormonal changes, inflammatory pathways and myocellular mechanisms leading to the development of sarcopenic obesity. We discuss the evolution, controversies and challenges in defining sarcopenic obesity and present current body composition modalities used to assess this condition. Epidemiological surveys form the basis of defining its prevalence and consequences beyond comorbidity and mortality. Current treatment strategies, and the evidence supporting them, are outlined, with a focus on calorie restriction, protein supplementation and aerobic and resistance exercises. We also describe weight loss-induced complications in patients with sarcopenic obesity that are relevant to clinical management. Finally, we review novel and potential future therapies including testosterone, selective androgen receptor modulators, myostatin inhibitors, ghrelin analogues, vitamin K and mesenchymal stem cell therapy.
Key points
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Body composition changes that occur with the ageing process can lead to sarcopenic obesity, an increasingly prevalent disorder owing to the increased prevalence of obesity in an ageing population.
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Hormonal, inflammatory and myocellular mechanisms impact underlying biological processes that promote fat deposition and loss of lean mass and strength.
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Definitions of sarcopenia and obesity can vary considerably, prompting difficulties in the diagnosis and epidemiological understanding of sarcopenic obesity as well as the development of treatment strategies for this disease.
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Lifestyle interventions including calorie restriction and physical activity consisting of aerobic and resistance exercises are the cornerstones of therapy.
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Clinicians and researchers need to be aware of weight loss-induced sarcopenia and osteopenia.
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Novel, promising therapies, including weight loss medications, bariatric surgery, whole-body vibration therapy, periodization (a systematic variation in physical training specificity, intensity and volume within periods), testosterone, selective androgen receptor modulators, anamorelin, myostatin inhibitors, vitamin K and mesenchymal stem cells, require further investigation.
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Acknowledgements
The authors would like to thank R. Masutani and R. Dokko for their help with preparing the manuscript and E. Weiss for contributing to the images in figure 2. J.A.B.’s research reported in this publication was supported in part by the US National Institute on Aging of the US National Institutes of Health under award number K23AG051681. Support was also provided by the Dartmouth Health Promotion and Disease Prevention Research Center supported by cooperative agreement number U48DP005018 from the Centers for Disease Control and Prevention and the Dartmouth Clinical and Translational Science Institute under award number UL1TR001086 from the US National Center for Advancing Translational Sciences. D.T.V.’s research was supported in part by DK109950 from the US National Institute of Diabetes, Digestive and Kidney Diseases, AG031176 from the US National Institutes on Aging, CX000906 from the Veterans Affairs Office of Research and Development, 1-14-LLY-38 from the American Diabetes Association and the Alkek Foundation. The content is solely the responsibility of the authors and does not necessarily represent the official views of the US National Institutes of Health or of the Department of Veterans Affairs, nor represents the official position of the Centers for Disease Control and Prevention.
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Glossary
- Sarcopenia
-
The loss of muscle mass, strength or physical function with age.
- Oxidative capacity
-
The maximal ability of muscle to utilize oxygen per g of muscle per hour.
- Thermic effect of food
-
The amount of energy expended owing to the body’s processing and storage of food.
- Fat-free mass
-
A term interchangeably used with muscle mass and lean mass; it refers to the mass of all visceral organs, muscles (smooth and skeletal), bones, ligaments and tendons but does not include fat that is present in the marrow of bones or internal organs.
- Waist circumference
-
An anthropometric measure of central obesity (subcutaneous and visceral) measured at the level of the iliac crest.
- Visceral fat
-
A measurement of the adiposity located among organs within the abdominal cavity; it is associated with inflammation and increased cardiometabolic risk.
- Intramyocellular lipids
-
Fat depositions within the muscle structure.
- Myostatin
-
A transforming growth factor-related protein that is synthesized and secreted in skeletal muscle and negatively regulates muscle mass and function.
- VO2 max
-
The maximal amount of oxygen used per kg of body weight during maximal exercise.
- Lean mass
-
A term that refers to the mass of all visceral organs, muscles (smooth and skeletal), bones, ligaments and tendons but excludes fat from bone.
- Appendicular lean mass
-
Muscle mass consisting of the sum of the upper and lower limbs.
- Grip strength
-
A measurement used in the ascertainment of upper extremity strength; it is assessed using the dominant hand with a hand-held dynamometer.
- Knee extensor strength
-
A measure of lower extremity strength. The test is performed using a dynamometer with the participant sitting with hips and knees flexed at 90°; the participant extends his or her knee and pushes against a resistance pad — the results are measured in kilograms or pounds.
- Quadriceps muscle area
-
Cross-sectional 2D area at the level of the quadriceps muscle of the lower limb.
- Skeletal muscle index
-
Absolute muscle mass (in kg) normalized for height (muscle mass in kg divided by height (in m)).
- Absolute muscle mass
-
Muscle mass consisting of all limbs and muscle from visceral organs.
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Batsis, J.A., Villareal, D.T. Sarcopenic obesity in older adults: aetiology, epidemiology and treatment strategies. Nat Rev Endocrinol 14, 513–537 (2018). https://doi.org/10.1038/s41574-018-0062-9
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DOI: https://doi.org/10.1038/s41574-018-0062-9
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