Thigh and calf circumference for the sarcopenia screening in community-dwelling elderly women

Satomi Kusaka1, *Tetsuya Takahashi1, Yoshinori Hiyama1, Yasuaki Kusumoto1, Junko Tsuchiya1, Masaru Umeda1
1Tokyo University of Technology, School of Health Sciences, Tokyo, Japan
DOI: 10.24816/jcgg.2017.v8i4.01

  • Abstract
  • Full Text
  • Reference

Objectives: The purpose of this study was to investigate usefulness and limitations of measurement of thigh and calf circumference for the sarcopenia screening in community-dwelling elderly women.

Methods: One-hundred sixteen community-dwelling elderly women were enrolled. Thigh and calf circumferences, grip strength, walking speed, Short Physical Performance Battery  and Timed Up test and Go test were performed. Subjects were divided into two groups, the non-sarcopenia group and the sarcopenia group, and the measured values were compared between the two groups. The area under the receiver operating characteristic curve was calculated to determine the cut off values of each circumstance were determined by the presence or absence of sarcopenia.

Results: Of all the subjects, non-sarcopenia subjects accounted for 91.4% (n=106), and sarcopenia subjects 8.6% (n=10). Thigh circumference and calf circumference of the dominant leg in sarcopenia subjects showed significant lower values than in non-sarcopenia subjects. Cut-off value for sarcopenia of thigh circumference was 37.3 cm (sensitivity 0.821, specificity 0.600, AUC 0.783, p<0.003), while that of the calf circumference was 32.8 cm (sensitivity 0.736, specificity 0.800, AUC 0.792, p<0.002).

Conclusions: We confirmed that thigh and calf circumference could be used as a sarcopenia screening in community-dwelling elderly women. Since measurement of calf circumference is easier and calf circumference has high specificity of sarcopenia screening than thigh circumference, calf circumference is thought to have higher measurement significance in community-dwelling elderly women.

INTRODUCTION

 

Sarcopenia increases with aging and it has been attracting great interest in aging society. Sarcopenia is defined as a state of illness associated with risks such as physical dysfunction, reduction in quality of life, and death that are induced by progressive reduction in muscle mass and muscle weakness.1 For the measurement of muscle mass, which is important for the diagnosis of sarcopenia, the dual energy X-ray absorptiometry method (DXA) and the bioelectrical impedance analysis method are used. However, it is problematic that they are not always available, accessible, or practical needing special-expensive devices.

In recent years, calf circumference has been attracting attention as a surrogate marker for the diagnosis of sarcopenia. Calf circumference is correlated with the appendicular skeletal muscle index that was measured by DXA and computed tomography,2 and is also known for its easy clinical application because it only needs to lift the hem of the lower wear when measuring. Kawakami et al. reported about the relationship between calf circumference and sarcopenia by describing that calf circumference is less than 33 cm could be a surrogate marker for the diagnosis of sarcopenia. On the other hand, since calf muscle is located more distal than the thigh, calf circumference is likely to be affected by edema depending on upright position time and measurement time which may affect the results eventually.

Thigh muscle mass is also reported to play a role as an indicator of muscle mass of the whole thigh muscle mass3 and total body muscle mass.4,5Thigh muscle is known as the primary agonist muscle of exercise and activities of daily life. Thigh muscle mass is found to be associated with sarcopenia-related indicators such as grip strength, knee extension muscle strength, walking speed, and TUG.4 While the importance of the thigh muscle is pointed out, the clinical significance of the thigh circumference is not fully understood. In addition, the possibility of using the thigh circumference as a sarcopenia screening tool has not been determined before. We hypothesized that the thigh circumference has higher clinically significance as a sarcopenia screening tool than the calf circumference because thigh muscle is the primary agonist muscle of exercise and activities of daily life.

In this study, therefore, we aimed to investigate usefulness and limitations of measurement of thigh and calf circumference for the sarcopenia screening in community-dwelling elderly women.

 

METHODS

 

Participants

 

A total of 116 community-dwelling women (age: 65-86) who applied for the public recruitment for an event of physical fitness assessment on April 21st and 29th in 2016 were enrolled. We included only women into this study because there were only a few men who applied for this event. This event was publicized through the Ota-ku municipal newsletter. To be enrolled, the candidates should meet the following requirements: they should (1) be aged

≥65 and living in Ota-ku, (2) feel their physical strength is declining and want to overcome it, (3) be willing to extend their healthy life expectancy. Exclusion criteria were as follows; 1) persons who cannot come to the research site on their own. 2) persons who are restricted in exercise from their medical doctor due to severe heart disease, respiratory disease, orthopedic disease, metabolic disease, etc. 3) Persons who develop movement disorders due to diseases of the central nervous system caused by cerebrovascular diseases. 4) Persons who have been diagnosed as having dementia in the past. Written informed consent was obtained from all the participants.

On the day of the examination, subjects were asked about their physical conditions and any pain they might have because of the exercise equipment. Once they were confirmed to have no problems, all the measurements were conducted on the same day.

 

Measures

 

The following measurement items were included: height, body weight, thigh and calf circumferences, skeletal muscle mass of the arm and leg, grip strength, bone density, Short Physical Performance Battery test (SPPB), and Timed Up and Go test (TUG).

Thigh circumferences and calf circumferences of the dominant leg were measured using a plastic measure with the subjects in a supine position on a bed. We set the dominant leg with reference to previous studies.2,8 The dominant leg was defined as the lower limb of the kicking side of the ball. For standardization of thigh circumference measurement, measurement site of thigh circumferences was the 1/2 point between the lateral knee joint cleft and the greater trochanter, and the calf circumference was measured at the maximum circumference of the lower leg. These circumference measurements were conducted once by one examiner after practicing sufficiently.

Body composition analysis was performed using a body composition analysis device (In Body S10, In Body Japan). The skeletal muscle mass and the body fat ratio were

measured using an electrode attached to the predefined position with the subjects in a supine position on a bed. Skeletal muscle Index (SMI) was calculated using following formula: appendicular SMM/body height2.

Grip strength of the subjects was measured in their standing position with their elbow joint bent at 90 degrees, using a hand dynamometer (Saehan medical, Jamar Hydraulic Hand Dynamometer SH5001). Two sessions of measurement were performed for both right and left hands alternately and whichever higher value was defined as the grip strength.

The SPPB was used to assess performance-based mobility in the lower extremities, which includes balance test, 4-meter walking test (4-m walking speed), and sit-to-stand test.

TUG test was performed allowing subjects to use walking aids they usually use. They stood up from their chairs and walked to the triangular post 3 meters ahead and made a U-turn back toward their chairs with the safe and maximum effort. TUG test was performed 2 times and we used whichever the faster speed for the analysis.

 

Statistical Analysis

 

Subjects were divided into the non-sarcopenia group and the sarcopenia group based on the criteria of the Asian Working Group for Sarcopenia (AWGS).6 The AWGS defined sarcopenia as the loss of muscle mass (<5.7 g/m2 in female by using bioimpedance analysis) plus low grip strength (<18 kg in female) or low usual gait speed (<0.8 m/s).

The following values between the two groups were compared: age (years old), height (cm), body weight (kg), BMI (kg/m2), body fat ratio (%), thigh circumference (cm), calf circumference (cm), thigh circumference adjusted by height, weight and BMI, calf circumference adjusted by height, weight and BMI, SMI (kg/m2), lower limb muscle mass of the dominant leg (kg), grip strength (kg), 4-m walking speed (m/s), TUG (s), and SPPB (points). We performed comparison analysis of these values between AWGS sarcopenia groups and non-sarcopenia group using Student’s t-tests if normally distributed. The total sum of SPPB scores (points) was compared using a Mann-Whitney test.

The area under the receiver operating characteristic (ROC) curve was calculated to determine thigh circumference, calf circumference and each circumference adjusted by height, weight and BMI. The cut off values of each circumstance were determined by the presence or absence of sarcopenia. All Statistical analyses were performed with SPSS Statistics version 22.0 for Windows (IBM Japan, Tokyo, Japan), and the significance level was set at 0.05 for all tests.

This study was approved by the Human Ethics Review of Tokyo University of Technology (approval number; E15HS-025).

 

RESULTS

 

Of all the subjects, non-sarcopenia subjects accounted for 91.4% (n=106), and sarcopenia subjects 8.6% (n=10).

 

When each measurement item was compared between both groups, significant low values in height, body weight, thigh circumference and calf circumference, lower limb muscle mass of the dominant leg, SMI, and grip strength were observed in the sarcopenia group (Table 1; p<0.05). Thigh circumference adjusted by weight and calf circumference adjusted by weight in the sarcopenia group showed significant higher values than those in the non-sarcopenia group (Table 1). There was a significant and positive correlation between thigh circumference and calf circumference (r=0.793, p <0.001).When each measurement item was compared between both groups, significant low values in height, body weight, thigh circumference and calf circumference, lower limb muscle mass of the dominant leg, SMI, and grip strength were observed in the sarcopenia group (Table 1; p

When the cut off value for sarcopenia was calculated using thigh circumference and calf circumference leg in the both groups, thigh circumference was 37.3 cm (sensitivity 0.821, specificity 0.600, AUC 0.783, SE 0.065, 95% CI 0.654-0.911, p <0.003), while calfcircumference was 32.8 cm (sensitivity 0.736,specificity 0.800, AUC 0.792, SE 0.056, 95% CI 0.683-0.901, p <0.002) (Figure 1).

We also calculated the cut off value for sarcopenia was using thigh circumference adjusted by weight and calf circumference adjusted weight. The cut off value of thigh circumference/weight was 0.80 (sensitivity 0.900, specificity 0.575, AUC 0.717, SE 0.081, 95% CI 0.557-0.877, p <0.024), while the cut off value of calf circumference/weight was 0.71 (sensitivity 0.800, specificity 0.811, AUC 0.792,  SE  0.069,  95%  CI  0.656-0.927, p<0.002).

DISCUSSION

 

The percentage of sarcopenia in this study population was 8.6%, which was equivalent to the previous study reported by AWGS.7 Kawakami et al.2 focused on calf circumference as a surrogate marker of sarcopenia diagnosis, and reported that calf circumference ≤33cm could be a surrogate marker of sarcopenia diagnosis for community-dwelling women. On the other hand, Ishii et al.8 reported that the presence or absence of sarcopenia is associated with age, grip strength, and calf circumference, and additionally reported that calf circumference in the non-sarcopenia women and the sarcopenia women were 34.5 ±2.7 cm and 32.1 ± 2.1 cm on average, respectively. Our results show that calf circumference in the non-sarcopenia women and the sarcopenia women were 34 cm and 32 cm on average, respectively (Table 1), and that the cut off value of calf circumference was 32.8 cm. This is line with the observations of Ishii et al.8 and Kawakami et al.2 Therefore, based on the results, the importance of calf circumference and the cut off value as a diagnosis tool of  sarcopenia in community-dwelling women was reconfirmed in our study as well.

In general, calf circumference is likely to be affected by edema depending on gravity since calf muscle is located more distal than the thigh. Thigh is less likely affected by gravity because of its higher position. Thigh is recognized as an important part of the lower limb because it works as the primary functional muscle for several activities in everyday life. There are several epidemiological studies measuring the thigh circumference. Ishii et al.8 measured thigh circumference at 15 cm above the patella regardless of the body build of the subjects and reported that thigh circumference of non-sarcopenia women and sarcopenia women were 41.7 ± 4.0 (cm) and 38.9 ± 3.4 (cm), respectively. However, they did not examine the cut off value of thigh circumference of sarcopenia. Murata et al. measured thigh circumference of elderly women and reported that the measurement site at 20 cm up (47.8 ± 4.1cm) from the upper edge of the patella was more associated with quadriceps strength than that at 10 cm up (40.6 ± 3.6 cm) and 15 cm up (44.7 ± 3.9 cm) from the upper edge of the patella.9 In this study, measurement was performed at the 1/2 between the lateral knee joint cleft and the greater trochanter. We found that thigh circumference of the dominant leg of the non-sarcopenia subjects and the sarcopenia subjects were 41.1 ± 4.0 (cm) and 37.4 ± 2.8 (cm), respectively. When compared our results with those of Ishii et al.,8 thigh circumference of the non-sarcopenia women in their study and our study were almost same, but thigh circumference of the sarcopenia women in our study was lower than that in their study. This difference may be due to the difference in measured location of thigh circumference.

Based on the thigh circumference of the dominant leg, the cut off value to differentiate the sarcopenia women and the non-sarcopenia women was 37.3 cm (sensitivity 0.821, specificity 0.600, AUC 0.783, p <0.003), while calf circumference of the dominant leg was 32.8 cm (sensitivity 0.736, specificity 0.800, AUC 0.792, p <0.002). Although both cut-off values for sarcopenia screening were obtained in thigh circumference and calf circumference of the dominant leg, specificity in the cut-off value of thigh circumference was relatively lower in than the cut-off value of calf circumference. In this study, calf circumference was measured at the maximum circumference of the lower leg, but thigh circumference was measured at the site of 1/2 point between the lateral knee joint cleft and the greater trochanter in consideration of the difference in body build of each subject. Thigh circumference at the site of 1/2 point between the lateral knee joint cleft and the greater trochanter was not always the maximum circumference of the thigh in each subject. This may be due to one of reason for lower specificity in the cut-off value of thigh circumference than in calf circumference for sarcopenia screening. Thigh muscles are the primary functional muscle of body movement. Thigh circumference measurement is easy and less time consuming; however, there was a limitation to screening only by measuring the single-site thigh circumference that might not the maximum circumference. Since measurement of calf circumference is easier and calf circumference has high specificity of sarcopenia screening than thigh circumference, calf circumference is thought to have higher measurement significance although neither thigh circumference nor calf circumference is a perfect screening tool for Sarcopenia diagnosis. Our hypothesis, the thigh circumference has higher clinically significance as a sarcopenia screening tool than the calf circumference was denied.

Finally, in this study, we found a significant difference in height, weight and BMI between non-sarcopenia group and sarcopenia group. Body size is thought to influence the difference in the circumference. Therefore, the thigh and calf circumference were adjusted by body height, weight and BMI. As a result, there was a significant difference in thigh circumference/weight and calf circumference/weight between the two groups. This may be due to fat mass included in the lower limbs. The specific gravity of fat is 0.900 g/cm3 and the specific gravity of lean body mass is 1.095/cm3. 10,11 This means that fat is weight less per 1 cm3, but volume is larger. It has been reported that the fat mass of the thigh muscle in sarcopenia is increased compared to non sarcopenia.12,13,14 Indeed, body fat percentage/weight was also significantly higher in the sarcopenia group in this study.

We also calculated the cut off value for sarcopenia using thigh circumference adjusted by weight and calf circumference adjusted weight. Thigh circumference / weight >0.80 or calf circumference / weight >0.71 may become a new sarcopenia screening index.

There were some limitations in this study. First, the number of subjects was relatively small. Secondly, data were collected from only a part of Tokyo. Thirdly, subjects were all females. Therefore, the findings of this study should be recognized as pilot study in nature. To verify the results of this study, further studies using more subjects including men in several areas are required.

 

CONFLICT OF INTEREST STATEMENT

 

No potential conflicts of interest were disclosed.

 

REFERENCES

 

  1. Cruz-Jentoft AJ, Baeyens JP, Bauer JM, Boirie Y, Cederholm T, Landi F, et al; European Working Group on Sarcopenia in Older Sarcopenia European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People. Age Ageing 2010;39:412-23.

View in Article

2. Kawakami R, Murakami H, Sanada K, Tanaka N, Sawada SS, Tabata I, et Calf circumference as a surrogate marker of muscle mass for diagnosing sarcopenia in Japanese men and women. Geriatr Gerontol Int. 2015;15:969-76.

• View in Article

3. Doxey The Association of Anthropometric Measurements of Thigh Size and B-mode Ultrasound Scanning of Muscle Thickness. J Orthop Sports Phys Ther. 1987;8:462-8.

• View in Article

4. Takahashi T, Sugie M, Nara M, Koyama T, Obuchi SP, Harada K, et Femoral muscle mass relates to physical frail components in community dwelling older people. Geriatr Gerontol Int. 2017;17(10):1636-41.

• View in Article

5. Ohkawa S, Odamaki M, Yoneyama T, Hibi I, Miyaji K, Kumagai Standardized thigh muscle area measured by computed axial tomography as an alternate muscle mass index for nutritional assessment of hemodialysis patients. Am J Clin Nutr. 2000;71:485-90.

• View in Article

6. Chen LK, Liu LK, Woo J, Assantachai P, Auyeung TW, Bahyah KS, et Sarcopenia in Asia: consensus report of the Asian Working Group for Sarcopenia. J Am Med Dir Assoc. 2014;15:95-101.

• View in Article

7. Chen LK, Lee WJ, Peng LN, Liu LK, Arai H, Akishita M; Asian Working Group for Recent Advances in Sarcopenia Research in Asia: 2016 Update From the Asian Working Group for Sarcopenia. J Am Med Dir Assoc. 2016;17:767.e1-7.

• View in Article

8. Ishii S, Tanaka T, Shibasaki K, Ouchi Y, Kikutani T, Higashiguchi Development of a simple screening test for sarcopenia in older adults. Geriatr Gerontol Int. 2014;14 Suppl 1:93-101.

• View in Article

9. Murata S, Ezaki C, Miyazaki J, Horie J, Murata J, Otao H. Relationship between configuration of the thigh and motor function in elderly Rigakuryoho kagaku. 2010;25:939-42. (in Japanese)

• View in Article

10. Heymsfield SB, Ebbeling CB, Zheng J, Pietrobelli A, Strauss BJ, Silva AM, et Multi-Component Molecular-Level Body Composition Reference Methods: Evolving Concepts and Future Directions. Obes Rev. 2015;16:282-94.

• View in Article

11. Duren DL, Sherwood RJ, Czerwinski SA, Lee M, Choh AC, Siervogel RM, et al. Body Composition Methods: Comparisons and Interpretation. J Diabetes Sci 2008;2:1139-46.

• View in Article

12. Kawai H, Kera T, Hirayama R, Hirano H, Fujiwara Y, Ihara K, et Morphological and qualitative characteristics of the quadriceps muscle of community-dwelling older adults based on ultrasound imaging: classification using latent class analysis. Aging Clin Exp Res. 2017; DOI 10.1007/s40520-017-0781-0.

           • View in Article

13. Sergi G, Trevisan C, Veronese N, Lucato P, Manzatoa Imaging of sarcopenia. European Journal of Radiology 2016;85:1519-24.

• View in Article

14. Watanabe Y, Yamada Y, Fukumoto Y, Ishihara T, Yokoyama K, Yoshida T, et al. Echo intensity obtained from ultrasonography images reflecting muscle strength in elderly men. Clinical Interventions in Aging 2013;8:993-8.

• View in Article

  1. Cruz-Jentoft AJ, Baeyens JP, Bauer JM, Boirie Y, Cederholm T, Landi F, et al; European Working Group on Sarcopenia in Older Sarcopenia European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People. Age Ageing 2010;39:412-23.
  2. Kawakami R, Murakami H, Sanada K, Tanaka N, Sawada SS, Tabata I, et Calf circumference as a surrogate marker of muscle mass for diagnosing sarcopenia in Japanese men and women. Geriatr Gerontol Int. 2015;15:969-76.
  3. Doxey The Association of Anthropometric Measurements of Thigh Size and B-mode Ultrasound Scanning of Muscle Thickness. Orthop Sports Phys Ther. 1987;8:462-8.
  4. Takahashi T, Sugie M, Nara M, Koyama T, Obuchi SP, Harada K, et Femoral muscle mass relates to physical frail components in community dwelling older people. Geriatr Gerontol Int. 2017;17(10):1636-41.
  5. Ohkawa S, Odamaki M, Yoneyama T, Hibi I, Miyaji K, Kumagai Standardized thigh muscle area measured by computed axial tomography as an alternate muscle mass index for nutritional assessment of hemodialysis patients. Am J Clin Nutr. 2000;71:485-90.
  6. Chen LK, Liu LK, Woo J, Assantachai P, Auyeung TW, Bahyah KS, et Sarcopenia in Asia: consensus report of the Asian Working Group for Sarcopenia. J Am Med Dir Assoc. 2014;15:95-101.
  7. Chen LK, Lee WJ, Peng LN, Liu LK, Arai H, Akishita M; Asian Working Group for Recent Advances in Sarcopenia Research in Asia: 2016 Update From the Asian Working Group for Sarcopenia. Am Med Dir Assoc. 2016;17:767.e1-7.
  8. Ishii S, Tanaka T, Shibasaki K, Ouchi Y, Kikutani T, Higashiguchi Development of a simple screening test for sarcopenia in older adults. Geriatr Gerontol Int. 2014;14 Suppl 1:93-101.
  9. Murata S, Ezaki C, Miyazaki J, Horie J, Murata J, Otao H. Relationship between configuration of the thigh and motor function in elderly Rigakuryoho kagaku. 2010;25:939-42. (in Japanese)
  10. Heymsfield SB, Ebbeling CB, Zheng J, Pietrobelli A, Strauss BJ, Silva AM, et Multi-Component Molecular-Level Body Composition Reference Methods: Evolving Concepts and Future Directions. Obes Rev. 2015;16:282-94.
  11. Duren DL, Sherwood RJ, Czerwinski SA, Lee M, Choh AC, Siervogel RM, et al. Body Composition Methods: Comparisons and Interpretation. J Diabetes Sci 2008;2:1139-46.
  12. Kawai H, Kera T, Hirayama R, Hirano H, Fujiwara Y, Ihara K, et Morphological and qualitative characteristics of the quadriceps muscle of community-dwelling older adults based on ultrasound imaging: classification using latent class analysis. Aging Clin Exp Res. 2017; DOI 10.1007/s40520-017-0781-0.
  13. Sergi G, Trevisan C, Veronese N, Lucato P, Manzatoa Imaging of sarcopenia. European Journal of Radiology 2016;85:1519-24.
  14. Watanabe Y, Yamada Y, Fukumoto Y, Ishihara T, Yokoyama K, Yoshida T, et al. Echo intensity obtained from ultrasonography images reflecting muscle strength in elderly men. Clinical Interventions in Aging 2013;8:993-8.