Introduction

Sarcopenia, or muscle loss, is a generalized skeletal muscle disorder with significant clinical implications. Until recently, sarcopenia was considered a geriatric syndrome characterized by age-related decline in muscle mass. However, secondary sarcopenia may result from other causal factors, unrelated to advancing age.1 Therefore, early diagnosis of sarcopenia is essential to optimize treatment outcomes. The understanding of sarcopenia has evolved over time, shifting from a sole focus on muscle mass to include diminished muscle strength and function as key diagnostic criteria.2,3 Irrespective of the definitions, sarcopenia is independently associated with a poor quality of life, risk of fractures and falls, and mortality.4–6 Sarcopenia has also been linked to various comorbidities, including congestive heart failure, chronic respiratory diseases, chronic liver diseases, diabetes, chronic kidney disease, and malignancy. Consequently, lifestyle changes, proper diet and physical activity are important in managing sarcopenia across various conditions.7

What is Known?

Box 1 shows the prevalence of sarcopenia across various regions.8–10

Box 1 Global and Regional Prevalence of sarcopenia

In a recent 2024 review, Alhmly et al analyzed the various definitions for sarcopenia across regions. The common measures for muscle mass in the European Working Group on Sarcopenia in Older People (EWGSOP) 2018 and the Asian Working Group for Sarcopenia (AWGS) 2019 include appendicular lean mass index and height squared (ALM/Ht²), with men <7.0 kg/m² and women <5.4 to 5.5 kg/m² (by dual-energy X-ray absorptiometry [DXA]).11 The EWGSOP 2018 sets handgrip strength (HGS) thresholds at <27 kg for men and <16 kg for women, whereas AWGS 2019 at <28 kg for men and <18 kg for women.11 In addition, the regional and ethnic differences between the West and Asia arise from unique anthropometric features and cultural or lifestyle distinctions.11

Although DXA is reliable for measuring skeletal muscle mass, due to its high cost and limited availability in South Asia, the South Asian Working Action Group on SARCOpenia (SWAG-SARCO) 2022 considers alternate measurements such as calf circumference (CC) (≤33 cm in females and ≤34 cm in males) or mid upper-arm circumference (MUAC) for muscle mass measurements.12 It further recommends an HGS cutoff value of <27.5 kg for men and <18 kg for women.12 However, no significant differences are seen in gait speed cutoffs (≤0.8 m/s to ≤1.0 m/s) suggested by the various working groups.

Figure 1 presents key highlights from diverse sarcopenia working groups.11,12

Figure 1 Exploring sarcopenia: Key highlights from diverse working groups on sarcopenia. Data from these studies.11,12

Abbreviations: AWGS, Asian Working Group on Sarcopenia; EWGSOP, European Working Groups on Sarcopenia in Older People; SWAG-SARCO, South Asian Working Group on SARCOpenia; 5-CST, 5-chair stand test.

The Need for Recommendations From the Indian Perspective

Although international guidelines provide evidence-based support, they lack population specificity and flexibility.13 The actual burden of sarcopenia remains underestimated and consequently undertreated, especially in lower- and middle-income countries (LMICs). This can be attributed to the cutoffs used for determining prevalence.3,14

Diagnostic equipment, such as hand dynamometers, is largely unavailable in clinical settings, particularly in LMICs, contributing to underdiagnosis.15 In general, Asians have smaller body sizes, lower muscle mass, and higher adiposity than their Western counterparts.12,16 Particularly, Indian diets are primarily cereal-based and are relatively low in protein quality.14 Lower socioeconomic status is associated with malnutrition and a higher risk of sarcopenia, especially among rural participants.16 The Kerala Diabetes Prevention Program found body mass index (BMI), a globally used obesity indicator, to be inadequate for the Indian population.17 The Lancet Commission 2025 highlights the insufficiency of BMI-based obesity diagnosis in a global context, proposing body fat measurements and health symptoms to be included.18 The cutoffs for metabolic syndrome in India are different from those of other countries.17 The available literature on the prevalence and diagnosis of sarcopenia in India is scarce and is based on cutoffs for Caucasian individuals.3 The agenda of this expert panel was to develop clinical recommendations specifically applicable to Indian patients with sarcopenia (Figure 2).

Figure 2 Breaking new ground: The distinctive novelty of this consensus.

Materials and Methods

A consensus was developed by a panel of 13 eminent subject-matter experts from various specialties such as endocrinology, general medicine, pulmonology, intensive care, geriatric medicine, dietetics, oncology, and sports medicine from India. The experts were selected based on their leadership roles in prestigious organizations, as presidents and secretaries of national and international societies, for their significant influence in shaping healthcare practices. Many have made research contributions, with numerous PubMed-indexed publications, editorial roles, and authorship of academic texts on topics such as endocrinology, geriatrics, diabetes, and critical care, with some focusing on rural healthcare, sports medicine, oncology, and nutrition. The steps followed for the consensus development have been summarized in Figure 3. A total of 45 consensus statements were framed, as presented in Supplementary Table 1.

Figure 3 From concept to consensus: Tracing the development steps. The criteria used to determine the level of agreement are as follows: High: When ≥75% of the participants agree/disagree with a statement. Moderate: When 55%–74% of the participants agree/disagree with a statement. Low: When <55% of the participants agree/disagree with a statement.

Discussion Epidemiology of Sarcopenia What Is the Burden of Sarcopenia in India?

Among the elderly (≥60 years of age) in India, primary sarcopenia has a prevalence of 39.2%.14

Grade of Recommendation (GOR): 3b; Level of Agreement (LOA): High

The Sarcopenia‑Chandigarh Urban Bone Epidemiological Study demonstrated that muscle mass is lower in Indians across all age groups than in Caucasians; hence, using Western cutoffs can overestimate the prevalence of sarcopenia in India.3

Sarcopenia is also highly prevalent in individuals with various comorbidities, as illustrated in Figure 4.14,19–24

Figure 4 Prevalence of sarcopenia in patients with various comorbidities. Data from these studies.14,19–23,24

Abbreviation: COPD, Chronic obstructive pulmonary disease.

What Is the Relationship Between Sarcopenia and Normal-Weight Obesity (NWO)?

NWO, a commonly encountered phenotype in South Asia, is associated with an increased risk of sarcopenia.25

GOR: 3b; LOA: High

Excessive body fat and a normal BMI are characteristics of NWO.26,27 An observational study showed that being in the NWO category meant a 22-fold higher risk of sarcopenia in males and 25-fold higher risk in females.25 The term sarcopenic obesity has been used for reduced muscle mass and increased body fat.28,29 A meta-analysis revealed the global prevalence of sarcopenic obesity in older adults to be 11%.30

Clinical Pearl

The prevalence of primary sarcopenia in India ranges from 14.2% to 39.2% in adults.4,31

Nearly one-fourth of patients with sarcopenia have accompanying obesity.2

Definition of Sarcopenia What Is the Definition of Sarcopenia That Is Relevant to the Indian Population?

Sarcopenia is a syndrome defined as a decrease in muscle function, strength, or mass.12

GOR: 1a; LOA: High

Different working groups on sarcopenia have proposed definitions for sarcopenia using various criteria, cutoff values, and diagnostic algorithms over the years.32 The definition of sarcopenia by SWAG-SARCO, which is particularly relevant for South Asia, equally emphasizes muscle strength, function, and mass.12

Handgrip strength (HGS) is a reliable and simple method to assess muscle strength.33

Clinical Pearl

Sarcopenia is defined as a decrease in any two of the following—muscle function, strength, or mass.

Etiopathogenesis of Sarcopenia What are the Risk Factors Associated With Sarcopenia?

A sedentary lifestyle, chronic inflammation, and poor nutritional status are contributing factors to sarcopenia.1,34

GOR: 1a/2b; LOA: High

Primary sarcopenia is physiological, whereas secondary sarcopenia could be attributed to multiple factors, namely diseases, poor lifestyle, inactivity, and malnutrition/obesity. In 2022, Verma et al showed a high sarcopenia prevalence of 46.7% in adults who led a sedentary lifestyle.27,35

The panel also opined that low muscle strength/mass is based on protein–calorie intake and vitamin D levels in childhood. The experts also mentioned that prolonged hospitalizations and poor diet after the usage of certain drugs, such as statins, are important contributing factors to sarcopenia.

Chronic Low-Grade Inflammation Is Associated With Various Comorbidities Such as Diabetes Mellitus, Chronic Respiratory Diseases, Cardiovascular Diseases, etc., Contributing to the Development of Sarcopenia GOR: 1a; LOA: High

Chronic inflammation associated with comorbidities accelerates skeletal muscle damage leading to secondary sarcopenia.35

Sarcopenia in patients with chronic kidney disease was shown to seriously worsen clinical prognosis.36 It also led to a 39% greater risk of incident cardiovascular disease (CVD) in comparison to those without sarcopenia.37

Sarcopenia Has a Bidirectional Relationship with Many Diseases

Sarcopenia has been recognized as one of the major contributing factors for frailty and may both be the cause and consequence of diabetes mellitus and impact the outcome of chronic obstructive pulmonary disorder (COPD).7,38

GOR: 2a/1a; LOA: High

The expert panel recognized the bidirectional relationship between sarcopenia and chronic diseases such as diabetes mellitus39 and COPD.38 Age, duration of diabetes, and diabetes-related complications could be risk factors for sarcopenia.40

Clinical Pearl

Chronic inflammation, in association with comorbidities, advances skeletal muscle loss, consequently precipitating secondary sarcopenia.

Clinical Features and Impact of Sarcopenia in Cancer and Critically Ill Patients What are the Outcomes of Cancers With Accompanying Sarcopenia?

Sarcopenia is associated with poor outcomes in cancer and increases the risk of complications.41

GOR: 1a/1b; LOA: High

The all-cause mortality rates in patients with breast cancer and hepatocellular cancer with sarcopenia were significantly higher than those without sarcopenia. Patients with digestive tract cancer and sarcopenia demonstrated increased risks of postoperative complications and a prolonged hospitalization compared to those without sarcopenia.41

Impact of Sarcopenia on Critically Ill Patients

Critically ill patients in the intensive care unit (ICU) lose approximately 2% of skeletal mass per day during the first week of admission and have a higher risk of mortality.42,43

GOR: 1a; LOA: High

A meta-analysis revealed a 48% prevalence of ICU-acquired sarcopenia.42 Critically ill patients diagnosed with sarcopenia face a 2.28-fold higher risk of mortality than patients without sarcopenia.42

Clinical Pearl

Sarcopenia is associated with an increased risk of all-cause mortality in patients with cancer and those who are critically ill.

Screening and Diagnosis of Sarcopenia

As suggested by the pool of evidence, sarcopenia shows a high prevalence in comorbid conditions, and the expert panel strongly recommended screening for sarcopenia in all patients with comorbidities.7,39,44

What are the in-Office Tests for Sarcopenia Assessment in Clinical Practice?

Simple measurements such as the CC or MUAC for muscle mass, HGS for muscle strength, and gait speed or 5-CST (5-chair stand test) for muscle function are quick and reliable in-office measurements/tests for assessing sarcopenia.1,12,45–47

GOR: 3b; LOA: High

Several proxy anthropometric measurements for sarcopenia assessments, namely MUAC and CC, show a good correlation with BMI.48 An MUAC ≤28.6 cm in men and ≤27.5 cm in women was indicative of low muscle mass.49

A concordance analysis for bioelectrical impedance analysis (BIA), anthropometry, and DXA demonstrated that CC showed 100% specificity for DXA-defined appendicular skeletal mass.45 The recommended cutoffs for CC by SWAG-SARCO are ≤34 cm for males and ≤33 cm for females.12

Table 1 Diagnostic Cutoffs for Clinical Assessment for Sarcopenia Assessment in India

Grip strength (GS) is a rapid and reliable test for sarcopenia and can effectively predict adverse outcomes (Table 1).1,12,46,47 Low muscle strength defined as <27.5 kg in males and <18.0 kg in females is recommended.3,12 Handgrip dynamometers are recommended widely for measuring GS.50 Innovations such as digital dynamometers have exhibited commendable validity and reliability in the measurement of isometric HGS in the general population.51

The strength, assistance with walking, rising from a chair, climbing stairs, and falls (SARC-F) questionnaire is a quick tool for bedside screening for sarcopenia.52,53 Gait speed can predict adverse outcomes in sarcopenia.1 The 5-CST test demonstrates high reliability in assessing lower limb strength, balance, and mobility in healthy elderly and those with pathologies, as indicated by relative inter-rater reliability scores (p<0.001).54

What Is the Role of Nutritional Assessment in Patients With Sarcopenia?

Since poor nutritional status and prognosis in patients with sarcopenia are strongly associated with comorbidities, nutritional assessment must be performed as a part of standard patient care.55,56

GOR: 1a; LOA: High

The SarcoPhAge study demonstrated an approximately 4-fold increased risk of developing sarcopenia/severe sarcopenia due to malnutrition.55 The Yishun Health study conducted in Singapore (in individuals aged 21–90 years) revealed that nutritional risk/malnourishment doubles or triples the odds of developing sarcopenia, and favorable Mini Nutritional Assessment parameter scores for food intake and BMI are positively linked with increased muscle mass and HGS (p<0.05).56 There was a broad consensus among the experts that nutritional assessment should be routinely recommended in sarcopenia.

What Imaging Tools Can Be Utilized to Screen and Diagnose Sarcopenia?

Imaging tests such as computed tomography (CT), magnetic resonance imaging (MRI), ultrasound (USG), DXA, or BIA may be conducted based on need and affordability.1,45,57

GOR: 1a; LOA: High

Although MRI and CT have been traditionally considered gold standards in noninvasive muscle mass assessments, their availability and affordability limit their utility in clinical settings.1,12 DXA is a useful tool with the advantages of low radiation exposure, affordability, and a fairly accurate estimation of body composition.45 BIA is based on prediction equations, and further studies are required to validate the equations for specific populations.1,45 The experts proposed USG as a good investigative modality besides the GS test for sarcopenia. A study on intra-rater and inter-rater reliability of ultrasound to quantify muscles in older adults or clinical populations showed that intraclass correlation coefficient (ICC) scores for reliability ranged from 0.26 to 1.00.57 It was also shown to be a valid method for muscle assessment, with ICC scores ranging from 0.92 to 0.999. Its high availability and low radiation exposure make it a practical tool for quantifying muscle mass.

The FRAX® tool can assess various clinical risk factors for osteoporotic fractures, which can be influenced by sarcopenia, as both conditions can coexist and exacerbate each other’s effects on musculoskeletal health.12,58

Which Muscle Is Most Suitable for Ultrasound Imaging in the Evaluation of Sarcopenia?

The rectus femoris and the psoas muscles are suitable alternatives for ultrasonographic assessment of sarcopenia.59–61

GOR: 3a/3b; LOA: High

Rectus femoris assessment is a promising method for the evaluation of sarcopenia, as it is easily accessible. However, clear protocols are necessary for the assessment.59 Psoas muscle measurements could be a surrogate measure.60,61 Most experts agree that the rectus femoris is the most suitable muscle for ultrasound. However, some experts expressed mixed opinions on the utility of the psoas muscle, as it is a minor muscle and fails to represent overall sarcopenia.1

Lacunae for Sarcopenia Screening in India

The experts reiterated the knowledge gap and the need for separate screening questionnaires for primary and secondary sarcopenia in India. They emphasized the need for specific guidelines on anthropometric measurement points and cutoffs to avoid ambiguity. Some experts suggested developing simplified ICU-specific screening questionnaires. They also endorsed the idea of a self-reporting questionnaire for people with sarcopenia.

Clinical Pearl

All patients with comorbidities should be screened for sarcopenia.7,39,44

A baseline HGS strength cutoff value of <27.5 kg in males and <18.0 kg in females can be defined as low muscle strength for the Indian population.3 A gait speed of 0.8 m/s suggests poor physical performance in adults aged over 60.3 A cutoff value of ≥12 seconds in the 5-CST may be considered poor physical performance in individuals with sarcopenia.32 Cutoff values for CC are <34 cm for males and <33 cm for females.12 USG of the rectus femoris is a practical imaging tool for the assessment of sarcopenia in clinical practice.59Monitoring of Sarcopenia What Is the Recommended Frequency of Monitoring in Patients With Sarcopenia?

Monitoring after diagnosis of sarcopenia should be done at least once in 3–6 months in symptomatic patients.

GOR: Expert Opinion; LOA: High

The experts also thought that initial assessments every 6 months for symptomatic patients (reduced GS, slow walking) followed by annual monitoring would be helpful. They mentioned that early monitoring that shows positive changes would encourage compliant patients to continue with their treatment. They opined that initial monitoring at 3 months would be preferable in acute sarcopenia.

What Is the Role of Biomarkers in Sarcopenia Monitoring?

The commonly used biomarkers for sarcopenia are total protein, hemoglobin, vitamin D, uric acid, magnesium, calcium, triglycerides, testosterone and estrogen, creatine phosphokinase, C-reactive protein, and erythrocyte sedimentation rate. The choice of biomarkers for monitoring patients with sarcopenia is at the discretion of the treating physician.12

Clinical Pearl

In symptomatic patients, the monitoring of sarcopenia should be done at least once in 3–6 months.

Prevention and Management of Sarcopenia What Measures and Interventions are Considered Effective in the Prevention and Management of Sarcopenia?

A minimum 12-week program of resistance exercise combined with nutritional supplementation can be recommended for the prevention and management of sarcopenia.62

GOR: 1a; LOA: High

Findings of a systematic review and meta-analysis of older adults diagnosed with sarcopenia revealed that resistance training, with or without nutritional support, and a combination of resistance, aerobic, and balanced training were the most effective for improving quality of life. Nutritional supplements with exercise showed a greater impact on HGS than exercise alone.63 Balance training can also assist individuals with sarcopenia in preserving stability during their routine activities and other tasks, thereby decreasing the likelihood of falls.64

Vitamin D supplementation along with beta-hydroxy-beta-methylbutyrate (HMB) enhanced muscle parameters in older adults, even when they did not engage in a physical exercise program.65 The NOURISH study (N=652) was a multicenter, double-blind, placebo-controlled trial. In the COPD subgroup (n=214) of malnourished adults aged ≥65 years, participants received either standard-of-care plus high-protein-HMB (HP-HMB) (n=109) or standard-of-care with a placebo supplement (n=105). The dosage was two servings per day (1.5 g of calcium-HMB), initiated within 3 days of hospital admission (baseline), and continued for up to 90 days after discharge. The supplementation of HP-HMB resulted in an approximately 71% lower mortality risk at 30, 60, and 90 days compared to the placebo. Furthermore, it led to a notable enhancement in HGS, an increase of +1.56 kg vs −0.34 kg (p=0.0413) from discharge to day 30, an increase in body weight from baseline to hospital discharge (0.66 kg vs −0.01 kg, p<0.05), and improvements in blood nutritional biomarker concentrations.66 In hospitalized older adults supplemented with HP-HMB, a reduced 90-day mortality was seen due to congestive heart failure, acute myocardial infarction, pneumonia, or COPD.67 A systematic review of 15 randomized controlled trails (N=2137) evaluating the effect of HMB or supplements with HMB showed improved muscle strength in addition to mass in various clinical groups, with a small–moderate effect size.68 In adults aged ≥65 years in Singapore, the SHIELD study found that nutritional supplements containing HMB and vitamin D significantly improved outcomes over 6 months compared to the placebo group. The intervention group showed significantly higher survival rates without hospital readmission along with increased weight gain, MUAC, and BMI compared to the placebo group throughout the study.34 Specialized nutrients such as calcium beta-hydroxy-beta-methylbutyrate (Ca-HMB), when used in the range of 1.5 to 3 g/day along with exercise, have been found to enhance muscle parameters in older adults.34,66–71

Growing evidence indicates that the supplementation with omega-3 polyunsaturated fatty acids yields positive effects in older adults with sarcopenia. Numerous studies have demonstrated the anti-inflammatory properties of omega-3 fatty acids (eicosapentaenoic acid and docosahexaenoic acid) leading to an augmentation in muscle protein. Administering 2 g/day for 6 months resulted in increased lean muscle mass, improved walking speed, and an increase in HGS and thigh muscle volume.38 Creatine enhances muscle strength, physical performance, and muscle mass. Its impact is evident when augmented by resistance training, as it increases the availability of energy during exercise.12Table 2 lists other nutrients that have been studied in the management of sarcopenia.12,38,69,72 Additional data are required on these nutrients to arrive at a definitive recommendation.

Table 2 Specialized Nutrients in Medical Nutrition Therapy (MNT) for the Management of Sarcopenia12,38,69,73

The experts encouraged the use of specific protein-rich food/recipes indigenous to their region. They were also of the view that early nutritional interventions and mobilization in patients admitted to the ICU via active/passive physiotherapy would help minimize skeletal muscle loss.73

Role of Drugs in the Management of Sarcopenia

Albeit with limited evidence, some drugs including anabolic steroids, alendronate, angiotensin-converting enzyme inhibitors, myostatin inhibitors, growth hormone, hormone replacement therapy, and calcium supplementation have been proven useful in the management of sarcopenia. Improved muscle function and physical performance were observed in studies with these drugs as a therapeutic approach to sarcopenia. However, further data are needed to provide clear recommendations.38,74,75

Can Testosterone Be Recommended in the Management of Sarcopenia?

Testosterone has shown a positive association with muscle strength.76 However, testosterone replacement therapy is linked to several adverse effects, including acne, gynecomastia, testicular atrophy, infertility, and liver toxicity among others.77 The panel was guarded in their recommendation and suggested the inclusion of a disclaimer on the contraindications of testosterone/estrogen when used in sarcopenia management.

Clinical Pearl

In people with sarcopenia, a combined intervention of resistance exercise and nutrition with specialized nutrients such as protein, HMB, and micronutrients for at least 3 months is recommended.12,34,38,63,69,70,72,78,79

Navigating the Future: Mapping the Path Ahead

A gap in knowledge exists regarding diagnostic cutoffs for sarcopenia assessment, the role of biomarkers in screening, and overall support strategies for sarcopenia in India.12

GOR: 1a; LOA: High

The diagnostic cutoffs and a practical algorithm for screening and managing sarcopenia in India have not yet been clearly defined. Simple, repeatable screening tools are desirable in clinical scenarios to identify patients predisposed to developing sarcopenia. Early diagnosis will lead to better functional outcomes and an eventual decrease in the sarcopenia burden in India. The experts were optimistic about the utility of artificial intelligence in sarcopenia. A pilot study was undertaken to assess the reliability and accuracy of measuring HGS between Squegg®, a smart dynamometer (handheld dynamometer with digital capabilities that facilitates Bluetooth connectivity to a mobile device, thereby enabling remote measurements), and a hydraulic hand dynamometer. Paired-samples t-tests showed no significant differences between the two devices. Intraclass correlation and Pearson correlations indicated good to excellent agreement.80 Artificial intelligence could assist clinicians in accurate diagnosis, avoiding the need for expensive imaging modalities.81 Due to a paucity of literature, further research is warranted in India. Figure 5 presents the algorithm for the diagnosis and management of sarcopenia.

Figure 5 Algorithm for the screening, diagnosis, and management of sarcopenia.

Abbreviations: BIA, Bioelectrical impedance analysis; CT, Computed tomography; CPK, Creatine phosphokinase; CRP, C-reactive protein, ESR, Erythrocyte sedimentation rate; F/U, Follow-up; Hb, Hemoglobin; HMB, Beta-hydroxy-beta-methylbutyrate; MRI, Magnetic resonance imaging; USG, Ultrasonography.

Eight Commandments in the Diagnosis and Management of Sarcopenia Approximately four out of 10 elderly adults and three out of 100 young adults suffer from sarcopenia in India. A sedentary lifestyle, chronic inflammation, and poor nutritional status are contributing factors to sarcopenia. Sarcopenia screening should be performed in all patients with comorbidities. The handheld dynamometer is a reliable tool for measuring muscle strength. SARC-F questionnaire can be used as a bedside tool for the assessment of muscle loss. Among Indians, cutoffs for HGS and other parameters are lower than the existing definitions of sarcopenia; hence, indigenous baseline HGS cutoffs of <27.5 kg in males and <18.0 kg in females can be defined as low muscle strength in the Indian population. Medical nutrition therapy, including calcium, vitamin D, proteins, creatine, HMB, and eicosapentaenoic acid for at least 3 months, is beneficial in managing sarcopenia. A minimum of 3 months of resistance training combined with oral nutritional supplementation can be recommended to prevent and manage sarcopenia. The frequency for the monitoring of sarcopenia can be 3‒6 months depending on the severity of symptoms.

The absence of region-specific guidelines poses challenges for sarcopenia assessment in India, resulting in inconsistencies in diagnosis and clinical management. This is the first Indian consensus to recommend diagnostic thresholds for muscle mass, strength, and physical function for the assessment of sarcopenia. It also proposes a comprehensive algorithm for screening, diagnosis, and management of sarcopenia tailored to the Indian population.

Conclusion

It is important to recognize the temporal variations in the Indian population when compared to the West. Due to differences in body types and genetic composition, it is necessary to adopt region-specific guidelines, particularly concerning sarcopenia indicators. This expert panel proposed suitable cutoffs for the Indian population to screen for sarcopenia, especially those with comorbidities. Swift diagnosis and intervention are crucial in managing sarcopenia. The handheld dynamometer has been suggested as a simple and reliable device to assess GS for clinical assessment. Measures such as physical activity and a protein-rich diet in at-risk populations, could play a key role in attenuating the progression of sarcopenia. Lifestyle modifications, including medical nutrition therapy and resistance exercise, were advocated as the mainstay in preventing and managing sarcopenia. Continued research is essential to further refine sarcopenia screening methods, treatment protocols, and regional guidelines, ensuring that they remain relevant to the evolving needs of the Indian population. By identifying current knowledge gaps, this expert panel offered a comprehensive set of recommendations for evaluating and managing sarcopenia in clinical practice in India (Figure 5).

Abbreviations

AWGS, Asian Working Group for Sarcopenia; BIA, Bioelectrical impedance analysis; BMI, Body mass index; Ca-HMB, Calcium beta-hydroxy-beta-methylbutyrate; CC, Calf circumference; COPD, Chronic obstructive pulmonary disorder; CT, Computed tomography; CVD, Cardiovascular disease; DXA, Dual-energy X-ray absorptiometry; EWGSOP, European Working Group on Sarcopenia in Older People; GOR, Grade of recommendation; GS, Grip strength; HGS, Handgrip strength; HMB, Beta-hydroxy-beta-methylbutyrate; HP-HMB, High-protein-HMB; ICC, Intraclass correlation coefficient; ICU, Intensive care unit; LMIC, Lower- and middle-income country; LOA, Level of agreement; MRI, Magnetic resonance imaging; MUAC, Mid-upper arm circumference; NWO, Normal-weight obesity; SWAG-SARCO, South Asian Working Action Group on SARCOpenia; USG: Ultrasound.

Data Sharing Statement

All data generated or analysed during this study are included in this article.

Author Contributions

All authors have made substantial contributions to this work, including conception, study design, execution, data acquisition, analysis, and interpretation and have all participated in the critical revision of the manuscript. All authors have agreed on the choice of the journal for submission, reviewed and approved all versions of the manuscript prior to submission, during revisions, upon final acceptance, and during the proofing stage. Furthermore, they accept responsibility and accountability for the content of the article.

Funding

This consensus was supported by Abbott Nutrition International, India.

Disclosure

SK discloses medical writing support from Abbott and speaker fee from Abbott, Signutra. IS, SS, and AD disclose that they are employees of Abbott. NK has received grants from the National Health and Medical Research Council of Australia, Indian Council of Medical Research and the Global Alliance for Chronic Diseases. He has also been a principal investigator for several Industry sponsored clinical trials for Novo Nordisk, Novartis, Eli Lilly and Amgen. SKV received a speaker honorarium from Boehringer, MSD, Torrent. VK, DL, and NS disclose support for the present manuscript from Abbott. PM discloses funding for the manuscript from Abbott. AGU, OPS, MT, AV, BBK, and KK declare no conflicts of interest in this work.

References

1. Cruz-Jentoft AJ, Bahat G, Bauer J, et al. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing. 2019;48(1):16–31. doi:10.1093/ageing/afy169

2. Pal R, Bhadada SK, Aggarwal A, Singh T. The prevalence of sarcopenic obesity in community-dwelling healthy Indian adults - The Sarcopenic Obesity-Chandigarh Urban Bone Epidemiological Study (SO-CUBES). Osteoporos Sarcopenia. 2021;7(1):24–29. doi:10.1016/j.afos.2020.12.003

3. Pal R, Aggarwal A, Singh T, et al. Diagnostic cut-offs, prevalence, and biochemical predictors of sarcopenia in healthy Indian adults: the Sarcopenia-Chandigarh Urban Bone Epidemiological Study (Sarco-CUBES). Eur Geriatr Med. 2020;11(5):725–736. doi:10.1007/s41999-020-00332-z

4. Brennan-Olsen SL, Bowe SJ, Kowal P, et al. Functional Measures of Sarcopenia: prevalence, and Associations with Functional Disability in 10,892 Adults Aged 65 Years and Over from Six Lower- and Middle-Income Countries. Calcif Tissue Int. 2019;105(6):609–618. doi:10.1007/s00223-019-00609-x

5. Xu J, Wan CS, Ktoris K, Reijnierse EM, Maier AB. Sarcopenia Is Associated with Mortality in Adults: a Systematic Review and Meta-Analysis. Gerontology. 2022;68(4):361–376. doi:10.1159/000517099

6. Wan SN, Thiam CN, Ang QX, Engkasan J, Ong T. Incident sarcopenia in hospitalized older people: a systematic review. PLoS One. 2023;18(8):e0289379. doi:10.1371/journal.pone.0289379

7. Sepúlveda‐Loyola W, Osadnik C, Phu S, Morita AA, Duque G, Probst VS. Diagnosis, prevalence, and clinical impact of sarcopenia in COPD: a systematic review and meta‐analysis. J Cachexia, Sarcopenia Muscle. 2020;11(5):1164–1176. doi:10.1002/jcsm.12600

8. Yuan S, Larsson SC. Epidemiology of sarcopenia: prevalence, risk factors, and consequences. Metabolism. 2023;144:155533. doi:10.1016/j.metabol.2023.155533

9. Weng SE, Huang YW, Tseng YC, et al. The Evolving Landscape of Sarcopenia in Asia: a Systematic review and meta-analysis following the 2019 Asian working group for sarcopenia (AWGS) diagnostic criteria. Arch Gerontol Geriatr. 2025;128:105596. doi:10.1016/j.archger.2024.105596

10. Patel MG, Makwana HH, Kalariya H, Kalariya H. Unraveling the enigma of sarcopenia and sarcopenic obesity in Indian adults with type 2 diabetes - a comparative cross-sectional study. Clin Diabetes Endocrinol. 2024;10(1):22. doi:10.1186/s40842-024-00179-4

11. Alhmly HF, Fielding RA. A Critical Review of Current Worldwide Definitions of Sarcopenia. Calcif Tissue Int. 2024;114(1):74–81. doi:10.1007/s00223-023-01163-3

12. Dhar M, Kapoor N, Suastika K, et al. South Asian Working Action Group on SARCOpenia (SWAG-SARCO) – a consensus document. Osteoporos Sarcopenia. 2022;8(2):35–57. doi:10.1016/j.afos.2022.04.001

13. Boshnjaku A, Krasniqi E. Diagnosing sarcopenia in clinical practice: international guidelines vs. population-specific cutoff criteria. Front Med Lausanne. 2024;11:1405438. doi:10.3389/fmed.2024.1405438

14. Rahman R, Wilson BP, Paul TV, Yadav B, Kango gopal G, Viggeswarpu S. Prevalence and factors contributing to primary sarcopenia in relatively healthy older Indians attending the outpatient department in a tertiary care hospital: a cross‐sectional study. AGING Med. 2021;4(4):257–265. doi:10.1002/agm2.12186

15. Ooi H, Welch C. Obstacles to the Early Diagnosis and Management of Sarcopenia: current Perspectives. Clin Interv Aging. 2024;19:323–332. doi:10.2147/CIA.S438144

16. Bhat G, Ireland A, Shah N, et al. Prevalence and factors associated with sarcopenia among urban and rural Indian adults in middle age: a cross-sectional study from Western India. PLOS Glob Public Health. 2024;4(10):e0003553. doi:10.1371/journal.pgph.0003553

17. Kapoor N, Lotfaliany M, Sathish T, et al. Obesity indicators that best predict type 2 diabetes in an Indian population: insights from the Kerala Diabetes Prevention Program. J Nutr Sci. 2020;9:e15. doi:10.1017/jns.2020.8.

18. Rubino F, Cummings DE, Eckel RH, et al. Definition and diagnostic criteria of clinical obesity. Lancet Diabetes Endocrinol. 2025;13(3):221–262. doi:10.1016/S2213-8587(24)00316-4

19. Dubey AK, Sahoo J, Vairappan B, Parameswaran S, Ps P. Prevalence and determinants of sarcopenia in Indian patients with chronic kidney disease stage 3 & 4. Osteoporos Sarcopenia. 2021;7(4):153–158. doi:10.1016/j.afos.2021.11.003

20. Chandrashekhar Iyer L, Vaishali K, Babu AS. Prevalence of sarcopenia in heart failure: a systematic review. Indian Heart J. 2023;75(1):36–42. doi:10.1016/j.ihj.2022.12.004

21. Kumar V, Benjamin J, Shasthry V, et al. Sarcopenia in Cirrhosis: fallout on Liver Transplantation. J Clin Exp Hepatol. 2020;10(5):467–476. doi:10.1016/j.jceh.2019.12.003

22. Sreepriya PR, Pillai SS, Nnkk N, Rahul A, Pillai S, Nair ATS. Prevalence and associated factors of sarcopenia among patients underwent abdominal CT scan in Tertiary Care Hospital of South India. J Frailty Sarcopenia Falls. 2020;5(3):79–85. doi:10.22540/JFSF-05-079

23. Gunasekar S, Deo S, Kumar S, Dhamija E, Bhoriwal SK. Prevalence of sarcopenia in patients with gastroesophageal and lung malignancies undergoing surgical resection and its impact on immediate postoperative outcomes: a prospective observational study. J Clin Oncol. 2021;39(15_suppl):e18617. doi:10.1200/JCO.2021.39.15_suppl.e18617

24. Yogesh M, Patel J, Makwana N, Mody M. The triad of physiological challenges: investigating the intersection of sarcopenia, malnutrition, and malnutrition-sarcopenia syndrome in patients with COPD - a cross-sectional study. BMC Pulm Med. 2024;24(1):71. doi:10.1186/s12890-024-02884-3

25. De Lorenzo A, Pellegrini M, Gualtieri P, Itani L, El Ghoch M, Di Renzo L. The Risk of Sarcopenia among Adults with Normal-Weight Obesity in a Nutritional Management Setting. Nutrients. 2022;14(24):5295. doi:10.3390/nu14245295

26. Kapoor N, Lotfaliany M, Sathish T, et al. Prevalence of normal weight obesity and its associated cardio-metabolic risk factors – results from the baseline data of the Kerala Diabetes Prevention Program. PLoS One. 2020;15(8):e0237974. doi:10.1371/journal.pone.0237974

27. Verma M, Kapoor N, Chaudhary A, et al. Prevalence and Determinants of Sarcopenic Obesity in Older Adults: secondary Data Analysis of the Longitudinal Ageing Study in India (LASI) Wave 1 Survey (2017–18). Adv Ther. 2022;39(9):4094–4113. doi:10.1007/s12325-022-02216-z

28. Hsu KJ, Liao CD, Tsai MW, Chen CN. Effects of Exercise and Nutritional Intervention on Body Composition, Metabolic Health, and Physical Performance in Adults with Sarcopenic Obesity: a Meta-Analysis. Nutrients. 2019;11(9):2163. doi:10.3390/nu11092163

29. Kalra S, Agrawal N, Kapoor N. Sarcopenic Obesity: anthropometric Diagnosis. J Pak Med Assoc. 2022;72(11):2337‒2338. doi:10.47391/JPMA.22-110

30. Gao Q, Mei F, Shang Y, et al. Global prevalence of sarcopenic obesity in older adults: a systematic review and meta-analysis. Clin Nutr. 2021;40(7):4633–4641. doi:10.1016/j.clnu.2021.06.009

31. Shaikh N, Harshitha R, Bhargava M. Prevalence of sarcopenia in an elderly population in rural South India: a cross-sectional study. F1000Research. 2020;9:175. doi:10.12688/f1000research.22580.1

32. Chen LK, Woo J, Assantachai P, et al. Asian Working Group for Sarcopenia: 2019 Consensus Update on Sarcopenia Diagnosis and Treatment. J Am Med Dir Assoc. 2020;21(3):300–307.e2. doi:10.1016/j.jamda.2019.12.012

33. Lovesley D, John S, Khakhar A, Ramakrishnan B, Ramamurthy A. Handgrip strength: a simple and effective tool to predict mortality after liver transplantation. Clin Nutr ESPEN. 2022;51:323–335. doi:10.1016/j.clnesp.2022.08.006

34. Chew STH, Tan NC, Cheong M, et al. Impact of specialized oral nutritional supplement on clinical, nutritional, and functional outcomes: a randomized, placebo-controlled trial in community-dwelling older adults at risk of malnutrition. Clin Nutr. 2021;40(4):1879–1892. doi:10.1016/j.clnu.2020.10.015

35. Bai T, Fang F, Li F, Ren Y, Hu J, Cao J. Sarcopenia is associated with hypertension in older adults: a systematic review and meta-analysis. BMC Geriatr. 2020;20(1):279. doi:10.1186/s12877-020-01672-y

36. Bellafronte NT, Sizoto GR, Vega-Piris L, Chiarello PG, Cuadrado GB. Bed-side measures for diagnosis of low muscle mass, sarcopenia, obesity, and sarcopenic obesity in patients with chronic kidney disease under non-dialysis-dependent, dialysis dependent and kidney transplant therapy. PLoS One. 2020;15(11):e0242671. doi:10.1371/journal.pone.0242671

37. Gao K, Cao LF, Ma WZ, et al. Association between sarcopenia and cardiovascular disease among middle-aged and older adults: findings from the China health and retirement longitudinal study. eClinicalMedicine. 2022;44:101264. doi:10.1016/j.eclinm.2021.101264

38. Mellen RH, Girotto OS, Marques EB, et al. Insights into Pathogenesis, Nutritional and Drug Approach in Sarcopenia: a Systematic Review. Biomedicines. 2023;11(1):136. doi:10.3390/biomedicines11010136

39. Veronese N, Pizzol D, Demurtas J, et al. Association between sarcopenia and diabetes: a systematic review and meta-analysis of observational studies. Eur Geriatr Med. 2019;10(5):685–696. doi:10.1007/s41999-019-00216-x

40. Feng L, Gao Q, Hu K, et al. Prevalence and Risk Factors of Sarcopenia in Patients With Diabetes: a Meta-analysis. J Clin Endocrinol Metab. 2022;107(5):1470–1483. doi:10.1210/clinem/dgab884

41. Xia L, Zhao R, Wan Q, et al. Sarcopenia and adverse health-related outcomes: an umbrella review of meta-analyses of observational studies. Cancer Med. 2020;9(21):7964–7978. doi:10.1002/cam4.3428

42. Fazzini B, Märkl T, Costas C, et al. The rate and assessment of muscle wasting during critical illness: a systematic review and meta-analysis. Crit Care. 2023;27(1):2. doi:10.1186/s13054-022-04253-0

43. Zhang XM, Chen D, Xie XH, Zhang JE, Zeng Y, Cheng AS. Sarcopenia as a predictor of mortality among the critically ill in an intensive care unit: a systematic review and meta-analysis. BMC Geriatr. 2021;21(1):339. doi:10.1186/s12877-021-02276-w

44. Pacifico J, Geerlings MAJ, Reijnierse EM, Phassouliotis C, Lim WK, Maier AB. Prevalence of sarcopenia as a comorbid disease: a systematic review and meta-analysis. Exp Gerontol. 2020;131:110801. doi:10.1016/j.exger.2019.110801

45. Sousa-Santos AR, Barros D, Montanha TL, Carvalho J, Amaral TF. Which is the best alternative to estimate muscle mass for sarcopenia diagnosis when DXA is unavailable? Arch Gerontol Geriatr. 2021;97:104517. doi:10.1016/j.archger.2021.104517

46. Gunasekaran V, Banerjee J, Dwivedi SN, Upadhyay AD, Chatterjee P, Dey AB. Normal gait speed, grip strength and thirty seconds chair stand test among older Indians. Arch Gerontol Geriatr. 2016;67:171–178. doi:10.1016/j.archger.2016.08.003

47. Dent E, Morley JE, Cruz-Jentoft AJ, et al. International Clinical Practice Guidelines for Sarcopenia (ICFSR): screening, Diagnosis and Management. J Nutr Health Aging. 2018;22(10):1148–1161. doi:10.1007/s12603-018-1139-9

48. Selvaraj K, Jayalakshmy R, Yousuf A, Singh AK, Ramaswamy G, Palanivel C Can mid-upper arm circumference and calf circumference be the proxy measures to detect undernutrition among elderly? Findings of a community-based survey in rural Puducherry, India. J Fam Med Prim Care. 2017 Apr-Jun;6(2):356–359. doi:10.4103/jfmpc.jfmpc_357_16

49. Hu FJ, Liu H, Liu XL, et al. Mid-Upper Arm Circumference as an Alternative Screening Instrument to Appendicular Skeletal Muscle Mass Index for Diagnosing Sarcopenia. Clin Interv Aging. 2021;16:1095–1104. doi:10.2147/CIA.S311081

50. Huang L, Liu Y, Lin T, et al. Reliability and validity of two hand dynamometers when used by community-dwelling adults aged over 50 years. BMC Geriatr. 2022;22(1):580. doi:10.1186/s12877-022-03270-6

51. Bairapareddy K, Khaleel A, Akbar S, et al. Validity and reliability of Squegg device in measuring isometric handgrip strength. Eur Rev Med Pharmacol Sci. 2023;27(21):10247–10254. doi:10.26355/eurrev_202311_34300

52. Singla N, Inavolu P, Kumar BR, Macherla R, Reddy DN. SARC-F Score: a Quick Bedside Tool to Screen Sarcopenia in Patients With Cirrhosis. J Clin Exp Hepatol. 2024;14(3):101318. doi:10.1016/j.jceh.2023.101318

53. Wu TY, Liaw CK, Chen FC, Kuo KL, Chie WC, Yang RS. Sarcopenia Screened With SARC-F Questionnaire Is Associated With Quality of Life and 4-Year Mortality. J Am Med Dir Assoc. 2016;17(12):1129–1135. doi:10.1016/j.jamda.2016.07.029

54. Muñoz-Bermejo L, Adsuar JC, Mendoza-Muñoz M, et al. Test-Retest Reliability of Five Times Sit to Stand Test (FTSST) in Adults: a Systematic Review and Meta-Analysis. Biology. 2021;10(6):510. doi:10.3390/biology10060510

55. Beaudart C, Sanchez-Rodriguez D, Locquet M, Reginster JY, Lengelé L, Bruyère O. Malnutrition as a Strong Predictor of the Onset of Sarcopenia. Nutrients. 2019;11(12):2883. doi:10.3390/nu11122883

56. Tan VMH, Pang BWJ, Lau LK, et al. Malnutrition and Sarcopenia in Community-Dwelling Adults in Singapore: yishun Health Study. J Nutr Health Aging. 2021;25(3):374–381. doi:10.1007/s12603-020-1542-x

57. Nijholt W, Scafoglieri A, Jager-Wittenaar H, Hobbelen JSM, van der Schans CP. The reliability and validity of ultrasound to quantify muscles in older adults: a systematic review. J Cachexia, Sarcopenia Muscle. 2017;8(5):702–712. doi:10.1002/jcsm.12210

58. Chandran M, Chin YA, Choo KS, et al. Comparison of the Osteoporosis Self-Assessment Tool for Asians and the fracture risk assessment tool - FRAX to identify densitometric defined osteoporosis: a discriminatory value analysis in a multi-ethnic female population in Southeast Asia. Osteoporos Sarcopenia. 2020;6(2):53–58. doi:10.1016/j.afos.2020.04.001

59. Nies I, Ackermans LLGC, Poeze M, Blokhuis TJ, Ten Bosch JA. The Diagnostic Value of Ultrasound of the Rectus Femoris for the diagnosis of Sarcopenia in adults: a systematic review. Injury. 2022;53:S23–S29. doi:10.1016/j.injury.2022.06.004

60. Hari A, Berzigotti A, Štabuc B, Caglevič N. Muscle psoas indices measured by ultrasound in cirrhosis — preliminary evaluation of sarcopenia assessment and prediction of liver decompensation and mortality. Dig Liver Dis. 2019;51(11):1502–1507. doi:10.1016/j.dld.2019.08.017

61. Yang D, Iqbal S, Rafatzand K, Scheede‐Bergdahl C. Psoas muscle measurement as a marker of sarcopenia predicts risk of Grade 4 or 5 baseline chronic kidney disease and its progression. JCSM Rapid Communications. 2022;5(2):182–193. doi:10.1002/rco2.63

62. Yamada M, Kimura Y, Ishiyama D, et al. Synergistic effect of bodyweight resistance exercise and protein supplementation on skeletal muscle in sarcopenic or dynapenic older adults. Geriatr Gerontol Int. 2019;19(5):429–437. doi:10.1111/ggi.13643

63. Shen Y, Shi Q, Nong K, et al. Exercise for sarcopenia in older people: a systematic review and network meta-analysis. J Cachexia, Sarcopenia Muscle. 2023;14(3):1199–1211. doi:10.1002/jcsm.13225

64. Cui H, Wang Z, Wu J, et al. Chinese expert consensus on prevention and intervention for elderly with sarcopenia (2023). AGING Med. 2023;6(2):104–115. doi:10.1002/agm2.12245

65. Rathmacher JA, Pitchford LM, Khoo P, et al. Long-term Effects of Calcium β-Hydroxy-β-Methylbutyrate