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Geriatr Gerontol Int 2014; 14 (Suppl. 1): 69–75

ORIGINAL ARTICLE

Prevalence and associated factors of sarcopenia and severe

sarcopenia in older Taiwanese living in rural community:
The Tianliao Old People study 04
Chih-Hsing Wu,1,9 Kuan-Ting Chen,2 Meng-Tzu Hou,3 Yin-Fan Chang,1 Chin-Sung Chang,1,8
Ping-Yen Liu,4,8 Shin-Jiuan Wu,5 Ching-Ju Chiu,9 I-Ming Jou6 and Chuan-Yu Chen7
1
Department of Family Medicine, 4Department of Internal Medicine, 6Department of Orthopedics, National Cheng Kung University
Hospital, 2Department of Medicine, College of Medicine, 8Graduate Institute of Clinical Medicine, College of Medicine, National Cheng
Kung University, 5Department of Food and Nutrition, Chung Hwa University of Medical Technology, Tainan, 9Institute of Gerontology,
National Cheng Kung University Medical College, Tainan, 3Department of Physical Therapy and Assistive Technology, National
Yang-Ming University, Taipei, and 7Department of Community Medicine, St. Martin De Poress Hospital, Chiayi, Taiwan

Aim: The aim of the present study was to show the prevalence and associated factors of sarcopenia and severe
sarcopenia in rural community-dwelling older Taiwanese.
Methods: Using the whole community sampling method, a total of 285 men and 264 women aged over 65 years
were randomly sampled (response rate = 50%) from Tianliao District, southern Taiwan, in 2012. Participants were
interviewed by trained investigators to complete a validated structural questionnaire. Body composition was measured
by bioelectrical impedance analysis, and skeletal muscle mass was estimated by Janssen’s equation. The Mini-
Nutritional Assessment (MNA) score, Short Portable Mental Status Questionnaire, grip strength, gait speed and short
physical performance battery (SPPB) were obtained by the standard procedures. Sarcopenia and severe sarcopenia
were defined according to the 2010 consensus of the Report of the European Working Group on Sarcopenia in Older
People.
Results: Of the 549 study participants, 39 (7.1%) were classified as having sarcopenia and 31 (5.6%) participants
were classified as having severe sarcopenia. Using multiple logistic regression models, the age, sex, working status,
waist circumference, body mass index, hypertensive history, MNA and SPPB score were independently associated
with different stages of sarcopenia.
Conclusions: Approximately one-fifth of community-dwelling older adults were facing the threat of sarcopenia in
southern Taiwan. The older age, female sex, lower body mass index, higher waist circumference, a history of
hypertension, lower MNA or SPPB score and not working regularly were associated factors for either sarcopenia or
severe sarcopenia. Geriatr Gerontol Int 2014; 14 (Suppl. 1): 69–75.

Keywords: bioelectrical impedance analysis, Mini-Nutritional Assessment, short physical performance battery,
skeletal muscle mass.

Introduction responsible for daily activities, sarcopenia has an influ-

Sarcopenia is named to reflect the status of decreased
skeletal muscle mass (SMM) in aging people.1 As the
SMM is one of the major human body components
Accepted for publication 2 December 2013.
Correspondence: Dr Chih-Hsing Wu MD, Department of
Family Medicine, National Cheng Kung University Hospital,
138 Sheng-Li Road, Tainan, 70428, Taiwan. Email:
paulo@mail.ncku.edu.tw
ence on self-independence in activities of daily living,
such as eating, taking a shower and walking,2–5 and
results in adverse outcomes, including falls, hip frac-
tures, comorbidities6–8 and mortality.9,10 Therefore, the
importance of sarcopenia is increasingly emphasized in
the aging society worldwide.6,11,12
It is believed that sarcopenia is an economic burden
for both caregivers and the healthcare system in an
aging society.12 However, there are still limited studies
or inconsistent prevalence of sarcopenia in Chinese
populations.3,5,9,13–18 In contrast, most of the reports were

© 2014 Japan Geriatrics Society doi: 10.1111/ggi.12233 | 69

 C-H Wu et al.
collected from subjects either living in nursing homes,15
hospital-based3,18 or as volunteers.13,14 Few studies
focused on the systemic sampling of older adults living
in metropolitan areas.9,16,17
Bioelectrical impedance analysis (BIA) is non-
radiating, relatively cheap and portable, making it
possible to measure body composition in rural commu-
nities. Many studies have shown that BIA-derived skel-
etal muscle mass index (SMI) can be used to define
sarcopenia,3,13,19,20 it is plausible to use BIA rather than
dual energy X-ray absorptiometry (DXA) to measure
the SMM in a community survey.
In 2010, the consensus of the Report of the European
Working Group on Sarcopenia in Older People
(EWGSOP) redefined the criterion for sarcopenia in
which not only the muscle mass is taken into consider-
ation, but muscle strength and muscle performance
are also considered for the definition of sarcopenia.21
Therefore, combined with muscle function and physical
performance, the level of decreased SMM was newly
categorized as presarcopenia, sarcopenia and severe
sarcopenia.21 The aging population is endemic, espe-
cially in rural townships. However, the healthcare facili-
ties are relatively inadequate when compared with that
in metropolitan areas. Therefore, to obtain the status of
sarcopenia in rural communities is urgent and impor-
tant for public health policy. To the best of our knowl-
edge, nearly none of the systemic sampling surveys of
sarcopenia have focused on the rural communities in
China or Taiwan. Furthermore, none of the studies
have reported the different stages of sarcopenia and the
associated risk factors concomitantly.
The aims of the present study were to determine the
prevalence of sarcopenia and severe sarcopenia of older
adults living in rural communities in southern Taiwan.
The associated factors of different stages of sarcopenia
were also evaluated accordingly. Through the compre-
hensive evaluation of sarcopenia in rural communities,
intervention and preventive strategy can be applied
appropriately.
Methods
In July 2012, a cross-sectional survey following the
Tianliao Old People (TOP) study22,23 was carried out in
Tianliao District, Kaohsiung City in southern Taiwan.
In the 2012 census report, in the total population of
7800, 1966 subjects (25.2% of the total population)
were aged 65 years and over. After excluding empty
houses (n = 489), death (n = 40), non-ambulatory sub-
jects (subjects with significant disabilities, such as
handicapped cerebral vascular accident, cancerous
cachexia, unstable chronic diseases or psychiatric dis-
orders, severe arthritis or inflammatory disease, uncom-
fortable anorexia by any medications, n = 138) and
non-reachable subjects (n = 201), a total of 285 men and
70 | © 2014 Japan Geriatrics Society
264 women, aged 65–102 years, were enrolled (response
rate: 549/1098 = 50%) by the whole district sampling
method.24 The sex distribution of the 549 respondents
was not statistically different from the 1417 non-
responders (P = 0.132). However, the mean age was
relatively younger for respondents (76.0 ± 6.2 vs 76.8 ±
7.4 years, P = 0.001). For convenience and accessibility,
all the participants received the survey in five locally
designated examination centers evenly distributed in the
Tianliao District. This study was approved by the insti-
tute review board of National Cheng Kung University
Hospital (IRB number: B-ER-101-119). Each partici-
pant signed an informed consent before examination.
Participants were interviewed to complete a validated
structural questionnaire,22,23 which included basic
characteristics, smoking and drinking habits, working
status, and medical history. We defined participants to
have a smoking habit if they had smoked more than 100
cigarettes and still smoked one pack (20 cigarettes) at
least per month for more than 6 months, and alcohol
drinking was defined by if participants still drank one
time per week for more than 6 months.23 A history of
hypertension or diabetes was assessed by referring to the
self-reported physician’s diagnosis. Participants who
still worked at a farm or had regular work were defined
as working regularly. The long form Mini-Nutritional
Assessment (MNA) was used as a screening tool to
evaluate nutritional status.25,26 Cognitive function was
evaluated by the wrong answer of the 10-item Short
Portable Mental Status Questionnaire (SPMSQ).27
Anthropometry and body composition
Bodyweight and standing height were measured by
DETECTO (Detecto, Webb City, MO, USA), with par-
ticipants dressed in light clothing and barefoot. Body
mass index (BMI) was calculated by bodyweight divided
by square of height (kg/m2). The waist circumference
(WC) was measured (Gulick II; Gays Mills, WI, USA;
to the nearest mm) midway between the lateral lower
rib margin and the superior anterior iliac crest at the
end of a gentle expiration phase.22 A single frequency
8-electrode bioelectrical impedance analysis (BIA)
device (BC-418; Tanita, Tokyo, Japan) was used to
measure body composition, which had been validated to
measure the SMM.28 SMM (kg) was estimated using the
Janssen’s equation:20 SMM = ([Ht2 / R × 0.401] + [sex ×
3.825) + (age × −0.071]) + 5.102, where height is in cm;
resistance is in ohms; for sex, men = 1 and women = 0;
and age is in years. SMM is divided by square of height
to obtain SMI (kg/m2) for defining low SMM and
sarcopenia.2,3,21
Physical performance
Functional limitations were assessed by using the
short physical performance battery (SPPB).29 A higher
 Sarcopenia in community-dwelling older Taiwanese
summary performance score represents a better perfor-
mance, and vice versa.30 In the present study, the SPPB
score was dichotomized as <9 or ≧9 for statistical analy-
sis.29,30 Two tests (30 s separately) of grip strength
(Grip-D; TKK 5401, Tokyo, Japan) of the bilateral
hands were obtained for each participant. The maximal
value of grip strength was used for the diagnosis of low
muscle function according to the corresponding cut-
offs by BMI and sex.21 In short, the corresponding cut-
offs of low grip strength for men with BMI ≤24 kg/m2,
24.1∼28 kg/m2, and >28 kg/m2 were ≤29 kg, ≤ 30 kg,
and ≤32 kg, respectively; for women with BMI ≤23 kg/
m2, 23.1∼26 kg/m2, 26.1∼29 kg/m2, and >29 kg/m2 were
≤17 kg, ≤17.3 kg, ≤18 kg, and ≤21 kg, respectively.21
The gait speed was assessed by a 15-ft walking test. Low
physical performance was determined when the gait
speed was ≤0.8 m/s.3
Definition of non-sarcopenia, sarcopenia and
severe sarcopenia
In the present study, we took the same young reference
values that have been validated by the National Health
Research Institute in Taiwan.3 In short, 498 healthy
males and 500 females aged 20–40 years were recruited
for body composition assessment using the same BIA
(BC-418) with segmental measures for developing the
reference SMI.3 With the definition of low muscle mass
set at two standard deviations below the mean value of
SMI in the young reference groups, the cut-off points
for men and women were 7.70 and 5.67 kg/m2, respec-
tively.3 Subjects were defined according to the 2010
consensus of Report of the European Working Group
on Sarcopenia in Older People.21 Those who had SMI
higher than the cut-offs3 were classified as normal. Low
SMM (also named as presarcopenia) was defined as
participants with SMI under two standard deviations of
the young reference of the same ancestry from 18 to 40
years-of-age.21 Sarcopenia was defined as participants
with low SMI and either low muscle function (reflected
by grip strength) or low physical performance (reflected
by walking speed). Severe sarcopenia was defined when
the aforementioned three conditions were present con-
comitantly.21 Normal and presarcopenia were reclassi-
fied as non-sarcopenia for statistical analysis.
Statistical analysis
Statistical analysis was carried out by using the Statisti-
cal Package of Social Science for Windows software
Version 17 (SPSSWIN, version 17.0; Chicago, IL,
USA). Continuous and categorical variables were
expressed as means ± SD and percentages, respectively.
The comparisons between groups in regard to categori-
cal variables were analyzed using the χ2-test, and
continuous variables were analyzed using one-way
© 2014 Japan Geriatrics Society
ANOVA. Multiple logistic regression models were
used to evaluate the independently associated factors
between different stages of sarcopenia. Statistical sig-
nificance was defined as P < 0.05 for two-tailed analysis.
Results
All the basic characteristics are shown in Table 1. Of the
549 subjects, including 285 males and 264 females,
101 (18.4%) subjects with 35 (12.3%) men and 66
(25.0%) women had SMI less than 7.70 and 5.67 kg/m2,
respectively.3 The prevalence of sarcopenia and severe
sarcopenia were 7.1% (n = 39) and 5.6% (n = 31),
respectively. Women had a higher prevalence of sarco-
penia and severe sarcopenia than men (Table 2). Non-
sarcopenic participants were younger, more likely to be
working regularly, had higher BMI, WC, SMI, MNA
and SPPB score, but lower gait speed and SPMSQ score
than sarcopenic and severe sarcopenic participants of
both sexes. No statistical difference of demographic
characteristics could be found between sarcopenia and
severe sarcopenia.
Using multiple logistic regression models, the associ-
ated factors for different stages of sarcopenia are shown
in Table 3. Age was a positive independent factor for all
stages of sarcopenia. BMI was a negative independent
factor for all stages of sarcopenia. Sex was an indepen-
dent factor in models I, II and III. WC was shown to be
an associated factor for all stages of sarcopenia, but was
only significant in model I. A lack of regular work was
an independent factor in model I. A History of hyper-
tension and low MNA score were also the independent
factors in model III. Low SPPB score was also an inde-
pendent factor in models II and IV. Other variables
including WC, habitual smoking, drinking alcohol,
history of diabetes and SPMSQ score showed no statis-
tic significance in all different stages of sarcopenia.
Discussion
Compared with studies carried out in Taiwan3,13,16,17 and
other countries,6,9,14,15,18,31,32 the prevalence of sarcopenia
and severe sarcopenia in Tianliao, Kaohsiung, is con-
sistently within the range of 5–30%. Interestingly, in the
present study, the prevalence of sarcopenia and severe
sarcopenia for women is notably higher than that of
men. Although men are supposed to have a higher
prevalence of sarcopenia than women because of the
higher rate of muscular atrophy than women,11 the
prevalence might be inverted while using different diag-
nostic criteria of sarcopenia.16,33 As the present study
was carried out in a farming village, most of the male
participants (50.2%) were still working more regularly
than the female participants (37.1%). Furthermore, gait
speed was higher in men than women (1.00 ± 0.28 m/s
| 71
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|
Table 1 Demographic characteristics of 549 older Taiwanese adults living in a rural community

Total Normal Presarcopenia Non-sarcopenia Sarcopenia Severe P-value*

sarcopenia
n 549 448 31 479 39 31 –
Age (years) 76.0 ± 6.2 75.2 ± 5.9 76.4 ± 5.9 75.3 ± 5.9 80.4 ± 5.9† 81.8 ± 5.7‡ <0.001
Sex (male/female) 285/264 250/198 12/19 262/217 11/28† 12/19‡ 0.002
Height (cm) 154.6 ± 8.4 155.2 ± 8.2 156.1 ± 7.6 155.3 ± 8.2 150.8 ± 8.4† 149.4 ± 8.8‡ <0.001
Weight (kg) 58.8 ± 10.9 61.1 ± 10.2 52.7 ± 7.7 60.5 ± 10.3 48.7 ± 7.5† 45.5 ± 7.2‡ <0.001
Body mass index (kg/m2) 24.6 ± 4.1 25.4 ± 3.9 21.6 ± 2.3 25.1 ± 4.0 21.5 ± 3.0† 20.4 ± 2.4‡ <0.001
Waist circumference (cm) 87.0 ± 10.3 88.8 ± 9.9 80.8 ± 7.1 88.3 ± 9.9 78.9 ± 9.2† 78.3 ± 8.5‡ <0.001
Skeletal muscle mass (kg) 18.1 ± 4.9 19.0 ± 4.7 15.1 ± 3.9 18.8 ± 4.7 13.3 ± 3.1† 13.5 ± 3.8‡ <0.001
Skeletal muscle mass index (kg/m2) 7.4 ± 1.5 7.8 ± 1.4 6.1 ± 1.2 7.7 ± 1.4 5.8 ± 0.9† 5.9 ± 1.1‡ <0.001
Working regularly (%) 44.0 48.3 38.7 47.7 18.4† 19.4‡ <0.001
Habitual smoking (%) 26.2 28.3 19.4 27.7 10.5 22.6 0.062
C-H Wu et al.

Alcohol drinking (%) 16.5 17.9 12.9 17.6 13.2 3.2 0.095
History of hypertension (%) 49.5 51.3 22.6 49.5 55.3 41.9 0.546
History of diabetes (%) 17.2 17.9 16.1 17.8 13.2 12.9 0.618
Mini-Nutritional Assessment score 25.9 ± 2.6 26.2 ± 2.3 25.6 ± 2.7 26.2 ± 2.3 23.4 ± 3.4† 24.2 ± 2.6‡ <0.001
SPMSQ score 1.9 ± 1.9 1.6 ± 1.5 2.9 ± 2.2 1.7 ± 1.8 3.0 ± 2.5† 3.0 ± 2.4‡ <0.001
Gait speed (m/s) 0.92 ± 0.29 0.94 ± 0.29 1.10 ± 0.18 0.95 ± 0.28 0.82 ± 0.22† 0.59 ± 0.14‡ <0.001
SPPB score ≧9 (%) 72.2 76.4 93.5 77.5 56.8† 9.7‡ <0.001
*Comparison between non-sarcopenia, sarcopenia and severe sarcopenia. Continuous variables: one-way ANOVA. Categorical variables: χ2-test. Comparison between
non-sarcopenia and sarcopenia: †P < 0.001. Comparison between non-sarcopenia and severe sarcopenia: ‡P < 0.001. Comparison between sarcopenia and severe sarcopenia:
non-significance. Non-sarcopenia: combined with normal and presarcopenia. SPMSQ, short portable mental status questionnaire; SPPB, short physical performance
battery.

© 2014 Japan Geriatrics Society

 Sarcopenia in community-dwelling older Taiwanese
Table 2 Prevalence of different stages of sarcopenia in 549 older
Taiwanese adults living in a rural community
Total
Case no. 549
Average age (years) 76.0 ± 6.2
Non-sarcopenia 479 (87.3%)
Normal 448 (81.7%)
Presarcopenia 31 (5.6%)
Sarcopenia 39 (7.1%)
Severe sarcopenia 31 (5.6%)
*Comparison between sex, χ2-test.
vs 0.83 ± 0.26 m/s), and grip strength was higher in men
than women (33.0 ± 7.82 kg vs 20.4 ± 5.20 kg) in the
present study (data not shown). Therefore, women
might have a higher prevalence of sarcopenia than
men,16 but this paradox needs to be reconfirmed by
further study.
Consistent with previous reports, age was the major
determinant of sarcopenia17,34 and physical perfor-
mance35 in the present study. Using the BIA-derived
SMM,3,13 the prevalence of sarcopenia defined by the
EWGSOP definition21 was found to be substantially
increased with age in both men and women.3 A higher
BMI indicates better nutrition intake24 and relatively
higher SMM.11 Therefore, BMI is negatively correlated
with the prevalence of sarcopenia,6–8,15,16,18 which is con-
sistent with our findings. The fact that the MNA was
not independently associated with sarcopenia after it
was adjusted with BMI might reflect the superiority of
BMI in relation to sarcopenia. Interestingly, the WC
showed a positive trend of low SMM after adjusting the
BMI and major variables in multiple logistic model
I. From the viewpoint of body composition, central
obesity might reflect the status of relatively higher bone
mass and abdominal fat accumulation, but lower fat
free mass.22 Central obesity is a well-known risk factor
of cardiovascular disease and metabolic aberrations.
Recently, SMI has been negatively correlated with
insulin resistance or C-reactive protein, and might share
the pathophysiological mechanism with non-alcoholic
fatty liver disease.36 Sarcopenia and WC could potenti-
ate each other to induce hypertension.37 In summary,
the association between low SMM and lower BMI or
higher WC is compatible with the concept of sarcopenic
obesity.33,38 The interrelationships between sarcopenia,
sarcopenic obesity, hypertension and metabolic syn-
drome have been emphasized,37,39 and warranted further
evaluation.
Studies have suggested that adequate physical activity
might reduce the risk of sarcopenia.34,40 In the present
study, the median and mean weekly calorie expenditure
(International Physical Activity Questionnaires) were
4587.8 kcal and 7914.2 kcal, respectively (data not
© 2014 Japan Geriatrics Society
Male Female P-value*
285 264 –
76.2 ± 6.5 75.9 ± 5.8 0.633
262 (91.9%) 217 (82.2%) <0.001
250 (87.7%) 198 (75.0%) <0.001
12 (4.2%) 19 (7.2%) 0.002
11 (3.9%) 28 (10.6%) <0.001
12 (4.2%) 19 (7.2%) 0.002
shown). However, participants who worked regularly
or had a higher SPPB score showed a lower risk of
sarcopenia in the present study. Grip strength and gait
speed are both the major surrogates of muscle function
and physical performance in combination with SMI for
the diagnosis of sarcopenia.21 As the association between
grip strength, gait speed and sarcopenia was inconsistent
in Chinese participants,5,35,41 the SPPB is not consistently
associated with different stages of sarcopenia. Neverthe-
less, physical performance should be measured univer-
sally beyond measurements of SMM.35
The present study had several limitations. First, the
cross-sectional study did not allow us to identify any
causal relationship. Second, only the ambulatory par-
ticipants were surveyed. Despite the 50% response rate
and locally designated examination centers, the preva-
lence of presarcopenia (low SMM), sarcopenia and
severe sarcopenia might still be underestimated. Third,
there are still some associated factors cannot be evalu-
ated adequately. As the Nagelkerke R2 values are 0.387–
0.563, most of the major factors were evaluated as
possible in the present study. Finally, the comparison of
the superiority of BIA-derived SMI with DXA-derived
SMI in the evaluation of sarcopenia is still inconclusive.
However, as the awareness of sarcopenia in recent
decade has improved, the cheap, portable and well-
validated BIA will become more popular in the near
future.
In conclusion, the prevalence of sarcopenia and
severe sarcopenia is 7.1% and 5.6%, respectively. Older
age, female sex, not working regularly, lower BMI,
higher WC, a history of hypertension, and lower MNA
or SPPB score were independently associated with
sarcopenia and severe sarcopenia in older Taiwanese
adults living in a rural community.
Acknowledgment
This work was supported by the Ministry of Education,
Taiwan, R.O.C. under the NCKU Aim for the Top
University Project (D101-35001). The authors thank
| 73
 C-H Wu et al.

the staff of Tianliao district Public Health Center for

(0.319∼0.684)***
(1.054∼1.300)**

(0.561∼0.892)**
Model I: normal (n = 448) versus participants with low skeletal muscle mass (n = 101). Model II: non-sarcopenia (n = 479) versus sarcopenia and severe sarcopenia (n = 70).
their generous support, as well as Ms Yu-Chen Shih for
Odds ratio (95% CI)

Model III: non-sarcopenia (n = 479) versus sarcopenia (n = 39). Model IV: non-sarcopenia (n = 479) versus severe sarcopenia (n = 31). *P < 0.05, **P < 0.01, ***P < 0.001.
(0.929∼1.169)
(0.082∼1.485)

(0.201∼2.186)
(0.346∼8.746)
(0.018∼2.175)
(0.900∼1.407)
(0.328∼3.147)
(0.324∼1.413)
(0.839∼1.413)
her administrative assistance.

Disclosure statement
Model IV
(n = 510)
Table 3 Multiple logistic regression models of the risk factors for sarcopenia and severe sarcopenia in 549 older Taiwanese adults living in

0.563
1.170
1.042
0.348
0.467
0.662
1.740
0.195
1.125
1.016
1.284
1.089
0.707
The authors declare no conflict of interest.

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