Sarcopenia Explained: Expert Advice on Protecting Your Muscle Strength as You Age

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While ageing and physical decline await us all, it’s not all a foregone conclusion. We do have some say in the matter! Paola Chellew gets to grips with the age-related condition known as sarcopenia and – with expert help from Dr Riekie Smit and functional fitness specialist Brenden Searle – finds out what you can do to prevent and potentially reverse some of the effects of this progressive muscular weakening.

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Sarcopenia is an age-related progressive loss of muscle mass and strength – its main symptom being muscular weakness. It affects people over 60, both sexes equally, as well as any ethnicity. The word sarcopenia derives from Greek origins, with sarx meaning ‘flesh’ and penia translating to loss. It could set in as early as your 30s and 40s, continuing at a rate of 3–5% loss of muscle per decade. The reason it’s important to address this issue is because of its consequences: less muscle leads to greater weakness, which leads to less mobility, which in turn may result in falls, fractures, and a shorter life expectancy.

I spoke to Dr Riekie Smit to get the medical facts.

What is sarcopenia?

Dr Riekie: Sarcopenia is the term used for the musculoskeletal disease that refers to the progressive loss of muscle mass and strength, particularly in older people. Sarcopenia is one of the key causes of the loss of independence and functional decline. It is a critical condition in the elderly, leading to frailty, disability, and an increased risk of falls and fractures.

The major misconception about sarcopenia is that it happens to everyone, as it’s a normal ageing progression. The truth is that sarcopenia could happen to everyone who is not actively doing something to prevent this progressive age-related muscle wasting. To understand how to prevent it, you must understand the condition and its causes.

Who does it affect?

Dr Riekie: Sarcopenia is a condition that most affects the elderly – but it can begin as early as your 30s! Muscle mass and strength decline in a linear fashion, with up to 50% of muscle mass being lost by your 70s. The worldwide prevalence of sarcopenia is estimated to be 10% in people over the age of 60.

The muscle mass of a normal human body accounts for up to 60% of body mass and has important metabolic and functional roles.

What are the causes and the symptoms?

Dr Riekie: The major causes of sarcopenia include the normal, multifaceted ageing processes on a cellular level.

There are, however, major factors contributing to the development and progression of sarcopenia:

• Physical inactivity
• Obesity
• Insulin resistance
• Reduced androgen and growth factor concentrations
• Inadequate protein intake
• Blunted muscle protein synthesis (MPS) response to protein meals or resistance exercise

There are also chronic diseases that will worsen or initiate sarcopenia, such as heart, lung, or kidney diseases, diabetes, HIV, and cancer.

The below images of MRI scans of a 40-year-old triathlete, compared to a 74-year-old sedentary man and a 70-year-old triathlete became very popular on numerous fitness websites. They provide a fitting example of how important physical activity is in the development of sarcopenia.

Are there any specific tests that can help diagnose the condition?

Dr Riekie: The first basic screening test to identify probable sarcopenia is the SARC-F questionnaire:

• Strength: Difficulty lifting and carrying 4–5kg.
• Assistance in walking: Difficulty walking across a room.
• Rise from a chair: Difficulty transferring from chair or bed.
• Climb stairs: Difficulty climbing up to 10 stairs.
• Falls: How many falls in one year.

A score of 4 points on the SARC-F is suggestive of sarcopenia.

Further tests include hand grip, chair stand, and other muscle strength tests. Tests to establish muscle mass may be done with bioelectrical impedance studies (BIA), which are the most widely used and most affordable. The most accurate imaging includes MRI, CT, and DEXA scans.

How is it treated?

Dr Riekie: Slowing the progression of muscle wasting includes a comprehensive plan:

• Physical activity, especially resistance training
• Increasing protein intake and quality through supplementation or food sources (animal protein sources are more effective than plant-based sources)
• Weight management
• Treating other diseases contributing to sarcopenia

Recent clinical trials on sarcopenia therapies such as physical exercise, and nutraceutical and pharmaceutical interventions have revealed that exercise is the only effective strategy shown to alleviate sarcopenia. Nonetheless, essential amino acid, fatty acid and vitamin D supplementation have shown benefits in specific cases.

There are also various new therapeutic approaches such as stem cell treatments, peptides, and muscle stimulation devices that are gaining popularity – with more studies being undertaken.

Another new development for sarcopenia is the use of high-intensity focused electromagnetic (HIFEM) muscle stimulation. These devices, such as the EmSculpt, have stimulated new muscle growth and reduced the muscle mass loss associated with sarcopenia.

What about medications?

Dr Riekie: Prescription medications for sarcopenia are developing and being studied currently. Medications used under strict medical supervision include testosterone, DHEA, growth hormone, and other hormonal replacements.

The field of regenerative medicine is a rapidly evolving field, with promising treatments becoming available.

What is your advice for a patient diagnosed with sarcopenia?

Dr Riekie: First, get a full medical work-up done for any other conditions that may contribute or be related to sarcopenia. Second, follow an integrative plan including exercise, nutrition, supplementation, and hormone replacement where needed.

I would strongly advise consultation with a nutritionist or dietician, as well as long-term management with a biokineticist at least once to twice weekly, as they specialise in improving physical condition and quality of life with physical assessments and correct exercises.

In my practice, I use the HIFEM muscle stimulation to induce muscle hypertrophy. These results are comparable to 12–16 weeks of intense exercise, even in patients over 60 years old!

Is this a condition that can be prevented or reversed?

Dr Riekie: It’s far easier to prevent than to try to reverse it. Prevention (and management) focuses on improving muscle protein synthesis (MPS) with resistance and aerobic training, coupled with high protein intake and maintaining a healthy weight.

A sedentary lifestyle tends to damage mitochondrial function and worsen insulin resistance, both leading to sarcopenia. An active lifestyle can involve family or friends, e.g. running/playing in the park or entering a race (like a 10 km run or mountain bike race).

Reward programmes such as Discovery Vitality or Momentum Multiply are great, as are reward systems available on fitness apps such as Strava, Garmin, Fitbit, and more.

Exercise should become part of everyone’s daily habits. This is the only real way to prevent sarcopenia.

As for exercise activities, some people may find spinning classes, CrossFit, dancing, or martial arts more attractive. For those introverts who prefer home workouts, there are many apps and a lot of YouTube content to help you be more active.

The important thing is to have a goal that you can work towards and then setting that goal higher after you have achieved it.

The muscle biopsies below show how innovative technologies such as HIFEM can help us to prevent and also manage sarcopenia.

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Insights from a functional fitness specialist

To round out the picture, I chatted with fitness guru Brendan Searle, who shares his views on sarcopenia, with a particular focus on the importance of exercise and nutrition.

We know that sarcopenia is a condition that is age-related. What other factors can cause it?

Brendan: Most people move, lift, and carry less as they age. The correlation between the mass of the objects we lift or carry on a daily basis is directly related to the rate at which sarcopenia progresses. That, in turn, is directly related to the extent to which ageing people move.

Another factor is the amount of protein and the overall energy intake balance that ageing people consume. Sarcopenic obesity – when skeletal muscle is so excessively infiltrated by fat that it renders muscle contraction more difficult, together with additional body fat weight – makes the movement extremely difficult for individuals who develop this condition.

To prevent the onset, or to reverse the early stages of sarcopenia, you need to engage in daily bouts of exercise that challenge the entire musculoskeletal system, together with nourishment, including sufficient quantities of protein.

In your profession, do you see cases of severe muscle loss?

Brendan: I have worked with men and women with advanced skeletal muscle loss, mostly as a consequence of not knowing the importance of adequate strength training and protein intake. In every case, all of these clients have responded positively to effective exercise and dietary programmes.

So, it’s never too late to start an exercise programme?

Brendan: No! I once trained an 85-year-old lady who was unable to walk up or down the stairs on a cruise ship. I began a muscle-strengthening programme with her at the start of the 90-day world cruise and by the end of it, she was able to disembark without her wheelchair. A year later, she was significantly stronger, gardening without assistance, diligently following her strength training programme, and had increased her daily protein intake.

What is resistance training and why is it necessary for building and maintaining the muscles in the body?

Brendan: Resistance training refers to exercise that engages muscle in overcoming forces: gravitational, aquatic, bands, as well as other mechanical forms of resistance such as isokinetic resistance machines. Lifting weights, doing exercises with body weight, or incorporating suspension training straps such as the TRX are popular and useful methods of providing sufficient resistance so that our bodies must respond by increasing muscle size and strength. The most effective modality of resistance training is using weights, as muscle groups are isolated and movement is made more possible with appropriate weights.

Resistance bands provide good concentric contraction stimulus for a muscle to grow or strengthen. Exercise in water provides resistance that can be increased by using hand paddles or foot fins, and has the potential to stimulate muscle growth if done as a power activity. 

Resistance training is vitally important in order to build and maintain skeletal muscle, as our bodies adapt to what we impose on them. If we impose inactivity, we lose muscle.

The opposite is also true: if we impose mechanical and metabolic stress on our muscles, our bodies register a need to grow muscle. Muscles become stronger to resist further stress by improving their capacity to overcome that stress.

Many women worry that working with weights will make them bulky. Explain what actually happens when you start lifting weights. 

Brendan: This is dependent on how much testosterone a woman produces; increases in muscle size and mass will happen accordingly. For women who are predisposed to producing more testosterone, using lighter weights for a longer set period, such as 20–30 reps, or 60 to 90 seconds, will result in muscle growth without extreme increase. Done correctly, weight training can assist women to improve muscle tone, density, and shape without the bulkiness associated with the use of heavier weights.

Talk to us about the importance of nutrition.

Brendan: You should eat sufficient quantities of high-biological-value protein on a daily basis: 1 g protein for every kg of lean body weight (if you have over 25% body fat), or 1 g protein per 1 kg body weight (if you are under 25% body fat). Fish, eggs, dairy, red meats, and poultry all contain high-biological-value proteins that include all nine essential amino acids, and are easy for our bodies to assimilate.

Plant proteins have a slightly lower NPU (net protein utilisation) value due to their fibre content, and do not have high levels of all nine essential amino acids; however, combining legumes with grains can provide all essential amino acids. New research suggests that elderly people do well in supplementing protein intake with collagen, particularly with regard to increasing muscle growth when implementing a resistance training programme focused on skeletal muscle hypertrophy.

The bottom line

We have to conclude that the loss of muscle and strength goes hand in hand with ageing, decreasing longevity and quality of life. Suddenly all those clichés become a reality: use it or lose it or you are what you eat!

Choose an exercise programme that is enjoyable and challenging, and make your food choices sustainable and interesting… after all, both need to be a way of life, not fads or trends. Get active, eat wisely, and have fun doing both – it’ll be worth it in the end.

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