Growing Menace of Sarcopenic Obesity - A South Asian Perspective

CME INDIA Presentation by Dr. Sanjay Kalra, MD, DM (AIIMS, New Delhi) Bharti Hospital, Karnal. With inputs from Prof. Nitin Kapoor, CMC Vellore.

Based on presentation at RSSDI RETREAT 29th May 2022, Pune.

Sarcopenia & Sarcopenic Obesity

Sarcopenic obesity is a condition of reduced lean body mass in the context of excess adiposity.
It is most often reported in older people, as both risk and prevalence increase with age.
Obesity exacerbates sarcopenia.
Obesity increases the infiltration of fat into muscle.
Obesity lowers physical function and increases risk of mortality Sarcopenic obesity is a distinct condition, and there are ongoing initiatives to improve its definition.

Increasing life expectancy in India

Growing Menace of Sarcopenic Obesity - A South Asian Perspective

Body composition changes with ageing

Sarcopenic obesity by body composition phenotype

Credit: Lee DC, Shook RP, Drenowatz C, Blair SN (Ref 1)

EWGSOP 2019 (European Working Group for the Study of Sarcopenia) defines

Probable Sarcopenia – Low muscle strength

Sarcopenia – Low muscle strength + Low muscle mass

Severe Sarcopenia – Low muscle strength + Low muscle mass Low physical performance

Hand grip – Dynamometer Low < 15 kg/m2
Relative Appendicular Skeletal Mass – <15 Kg/m2(women)
Appendicular lean mass – Lean Mass (Arms+legs) – 5.5 kg/m2(women)

Definition of Sarcopenia

Based on a review of the recommendations by four major working groups following recommendations by SWARG-SARCO

Credit: Ref (1)

South Asian Working Action Group on SARCOpenia (SWAG-SARCO) – A consensus document

“This South Asian consensus gives equal importance to muscle function, muscle strength, and muscle mass; provides cost-effective clinical and easy to implement solutions; highlights secondary sarcopenia and sarcopenic obesity; lists commonly used biomarkers; reminds us that osteo-arthro-muscular triad should be seen as a single entity to address sarcopenia; stresses on prevention over treatment; and prioritizes non-pharmacological over pharmacological management.”

Diagnostic cut points

Credit: Lee DC, Shook RP, Drenowatz C, Blair SN. Future Sci OA. 2016 Jul 14;2(3):FSO127.

Definition of Sarcopenic Obesity

Credit: Lee DC, Shook RP, Drenowatz C, Blair SN. Future Sci OA. 2016 Jul 14;2(3):FSO127.

Approach

Credit: Cruz-Jentoft AJ, Bahat G, Bauer J, Boirie 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. doi: 10.1093/ageing/afy169

Why is it important in clinical practice?

Pathophysiology, Clinical relevance, Complications

Credit: Eun Roh & Mook Choi Front. Endocrinol., 21 May 2020 | https://doi.org/10.3389/fendo.2020.00332

Credit: Kalinkovich A, Livshits G. Ageing Res Rev. 2017 May;35:200-221. doi: 10.1016/j.arr.2016.09.008. Epub 2016 Oct 1.

Sarcopenia & Obesity – A vicious cycle

Credit: Kalinkovich A, Livshits G. Ageing Res Rev. 2017 May;35:200-221. doi: 10.1016/j.arr.2016.09.008. Epub 2016 Oct 1.

Complication

Higher prevalence of diabetes, hypertension & dyslipidemia
Higher mortality
Depression
Higher frailty, disability and admissions

The MOAN (Musculo-Osteo-Arthro-Neuropathic) syndrome

The MOAN (musculo-osteo-arthro-neuropathic) syndrome highlights the close relationship between these four organ-systems, and their contribution to each other’s health and disease.
The mnemonic MOAN also underscores the discomfort and pain associated with the condition and encourages health professionals to address these patients in a holistic manner, rather than just addressing one of the components.

How do we manage?

The role of Diet, Exercise and Medicine

Credit: Lee, Shook, Drenowatz & Blair. Future Sci. OA 2(3), FSO127

What works?

Resistance training (RT) appears effective in the prevention of all components.
It does significant improvements in muscular mass, strength, and functional capacity plus loss of fat mass.
It works well especially when coupled with hypocaloric diets containing at least 0.8 g/kg body weight protein. Correction of vitamin D deficit has a favourable effect on muscle mass.
Intense and prolonged RT, diets with higher (1.2 g/kg body weight) protein content, and soy isoflavones all look promising.

Barocrinology: The Endocrinology of Obesity from Bench to Bedside

The authors proposed “Barocrinology,” a novel terminology in medical literature
It comprehensively describes the field of obesity medicine highlighting the role of knowing endocrine physiology for understating its evolution, insights into its complications and appreciating the changes in the hormonal milieu following weight loss therapies including bariatric surgery.
Barocrinology, coined as a portmanteau of “baro” (weight) and endocrinology, focuses upon the endocrine and metabolic domains of weight physiology and pathology.

Benefits of Exercise

Advise your patients

Chair exercises

Repetitions of toe raises, heel raises, knee lifts, and knee extensions. Gradually progressing from one to three sets of 10 squats, standing knee lifts, gluteal kicks, etc.

Resistance band exercise

Resistance bands were used for upper and lower body strengthening.

Hydraulic exercise machine

The participants rotated training machines between seated row, leg press, abduction and leg extension, beginning with one set of 10 repetitions to three sets.

Aerobic training

The participants pedaled on a stationary bicycle for 12 minutes, including 1 minute of cooldown, starting at 40 watts. The watt level was gradually increased throughout the 3 months based on each individual’s progress.

Points of Illumination

Lifestyle interventions, including caloric restriction and physical activity, are the cornerstones of Sarcopenic obesity treatment.
1-1.2 gm of proteins per day. Adequate Protein intake must be ensured to build muscle mass and strength.

Consensus on Medical Nutrition Therapy for Diabesity (CoMeND) in Adults: A South Asian Perspective

Credit: Kapoor N, Sahay R, Kalra S, Diabetes Metab Syndr Obes. 2021 Apr 16;14:1703-1728. doi: 10.2147/DMSO.S278928.

Numbers to note

25g: 100 g meat/chicken

23g: paneer

20g: Bhat ki Dal

19g: Chickpea

18.6g: Bengal Gram

12g: Greek yoghurt

10g: tofu

9g: lentils

6g: large egg

4g: milk

LEMON Mnemonic used as rubric for the evaluation of fatigue, reminds to promote Healthy life style.

Only Testosterone replacement is not enough.

L-Life Style

E-Endocrine

M-Medical/Metabolic

O-Observer induced or Iatrogenic

N-Nutritional

Combined Strategy works better

Final Point

CME INDIA Tail Piece

“Obesity can independently lead to loss of muscle mass and function, due to the negative impact of adipose tissue-dependent metabolic derangements, such as oxidative stress, inflammation and insulin resistance, all of which negatively affect muscle mass” – Hong SH, Choi KM

References:

Lee DC, Shook RP, Drenowatz C, Blair SN. Physical activity and sarcopenic obesity: definition, assessment, prevalence and mechanism. Future Sci OA. 2016 Jul 14;2(3):FSO127.
Cruz-Jentoft AJ, Bahat G, Bauer Jet al. 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. doi: 10.1093/ageing/afy169. Erratum in: Age Ageing. 2019 Jul 1;48(4):601. PMID: 30312372; PMCID: PMC6322506.
South Asian Working Action Group on SARCOpenia (SWAG-SARCO) – A consensus documentMay 2022.Osteoporosis and Sarcopenia DOI:10.1016/j.afos.2022.04.00
Kalinkovich A, Livshits G. Sarcopenic obesity or obese sarcopenia: A cross talk between age-associated adipose tissue and skeletal muscle inflammation as a main mechanism of the pathogenesis. Ageing Res Rev. 2017 May;35:200-221. doi: 10.1016/j.arr.2016.09.008. Epub 2016 Oct 1. PMID: 27702700.
Kalra S, Kumar V, Kapoor N. The MOAN (Musculo-Osteo-Arthro-Neuropathic) syndrome. J Pak Med Assoc. 2022 Feb;72(2):373-374. doi: 10.47391/JPMA.022-37. PMID: 35320199.
Petroni ML, Caletti MT, Dalle Grave R, Bazzocchi A, Aparisi Gómez MP, Marchesini G. Prevention and Treatment of Sarcopenic Obesity in Women. Nutrients. 2019 Jun 8;11(6):1302. doi: 10.3390/nu11061302. PMID: 31181771; PMCID: PMC6627872.
S.kalra.Nitin Kapoor et alMedBarocrinology: The Endocrinology of Obesity from Bench to Bedside. Sci. 2020, 8(4), 51; https://doi.org/10.3390/medsci8040051
Kalra S, Mandlekar A, Kapoor N. Exercise therapy for the exercise naïve: The first step in obesity management. J Pak Med Assoc. 2021 Dec;71(12):2828-2830. PMID: 35150550.
Koliaki C, Liatis S, Dalamaga M, Kokkinos A. Sarcopenic Obesity: Epidemiologic Evidence, Pathophysiology, and Therapeutic Perspectives. Curr Obes Rep. 2019 Dec;8(4):458-471. doi: 10.1007/s13679-019-00359-9. PMID: 31654335.
Kapoor N, Sahay R, Kalra S, Bajaj S, Dasgupta A, Shrestha D, Dhakal G, Tiwaskar M, Sahay M, Somasundaram N, Reddy R, Bhattacharya S, Reddy VB, Viswanathan V, Krishnan D, Baruah M, Das AK on Medical Nutrition Therapy for Diabesity (CoMeND) in Adults: A South Asi. Consensus an Perspective. Diabetes Metab Syndr Obes. 2021 Apr 16;14:1703-1728. doi: 10.2147/DMSO.S278928. PMID: 33889005; PMCID: PMC8057793.
Kalra S, Kalhan A, Dhingra A, Kapoor N. Management of late-onset hypogonadism: person-centred thresholds, targets, techniques and tools. J R Coll Physicians Edinb. 2021 Mar;51(1):79-84. doi: 10.4997/JRCPE.2021.121. PMID: 33877144.
Trouwborst, I.; Verreijen, A.; Memelink, R.; Massanet, P.; Boirie, Y.; Weijs, P.; Tieland, M. Exercise and Nutrition Strategies to Counteract Sarcopenic Obesity. Nutrients 2018, 10, 605. https://doi.org/10.3390/nu10050605
Eun Roh & Mook Choi Front. Endocrinol., 21 May 2020 | https://doi.org/10.3389/fendo.2020.00332
Hong SH, Choi KM. Sarcopenic Obesity, Insulin Resistance, and Their Implications in Cardiovascular and Metabolic Consequences. Int J Mol Sci. 2020 Jan;21(2):494