JAMDA xxx (2020) 1e5

JAMDA
journal homepage: www.jamda.com

Original Study

Comparison of Three Screening Methods for Sarcopenia in

Community-Dwelling Older Persons
Yi-Han Mo BSc a, Jing Zhong MSc a, Xin Dong BSc a, Yi-Dong Su BSc a, Wen-Yu Deng BSc a,
Xue-Mei Yao BSc a, Bei-Bei Liu BSc a, Xiao-Qin Wang PhD b, *, Xiu-Hua Wang PhD a, *
a
Xiang Ya Nursing School, The Central South University, Changsha, China
b
Department of Geriatrics, The Second Xiangya Hospital of Central South University, Changsha, China

a b s t r a c t

Keywords: Objective: The 2019 Asian Working Group on Sarcopenia in Older People (AWGS 2019) recommends using
Calf circumference either calf circumference or the strength, assistance in walking, rising from a chair, climbing stairs, and
older adults falls (SARC-F) or SARC-F combined with calf circumference (SARC-CalF) questionnaires for sarcopenia
sarcopenia
screening. The aim of this study was to compare the ability and applicability of calf circumference,
screening
SARC-F, and SARC-CalF for screening sarcopenia among community-dwelling older adults.
Design: Cross-sectional study.
Setting and Participants: A total of 1050 community-dwelling older people were enrolled.
Methods: Sarcopenia was diagnosed according to the AWGS 2019 criteria: bioimpedance analysis for
appendicular skeletal muscle index, hand grip, and 6-m gait speed test. Participants also completed the
SARC-F questionnaire and calf circumference measurement. The screening tools’ performances were
evaluated through receiver operating characteristic (ROC) curves, area under the ROC curves (AUC), and
sensitivity/specificity analyses.
Results: Sarcopenia was identified in 263 (25.0%) participants by the AWGS 2019 criteria. Calf circum-
ference had a sensitivity of 81.4% and a specificity of 77.0%. Sensitivity and specificity of SARC-F for
screening sarcopenia were 17.9% and 93.7%, respectively. SARC-CalF improved the sensitivity of SARC-F
(47.5%) while keeping similar specificity (92.0%). The AUCs of calf circumference, SARC-F, and SARC-
CalF were 0.79 [95% confidence interval (CI), 0.77e0.82], 0.56 (95% CI, 0.52e0.59), and 0.70 (95% CI,
0.67e0.73), respectively. The differences across ROC curves were statistically significant among 3
screening tools (P < .001).
Conclusions and Implications: The overall screening ability of calf circumference was better than that of
SARC-F and SARC-CalF for sarcopenia in community-dwelling older persons despite gender, age, and
cognitive function. SARC-F and SARC-CalF have high specificity but are susceptible to the preceding factors.
Ó 2020 AMDA e The Society for Post-Acute and Long-Term Care Medicine.

Aging is associated with changes in body composition, leading to
its functional decline and negative health outcome.1 Sarcopenia is one
of the major health problems among older adults.2 It is defined as age-
The authors declare no conflicts of interest.
This work was supported by the Central South University (Grant 2019zzts1036);
the Science and Technology Department of Hunan provincial (Grant 2018SK21312)
and Finance Department of Hunan Provincial (Grant 2050204e30299). The sponsor
had no role in the design, methods, subject recruitment, data collections, analysis
and preparation of paper.
* Address correspondence to Xiu-Hua Wang, PhD, Xiang Ya Nursing School, The
Central South University, Changsha 410013, China; or Xiao-Qin Wang, PhD,
Department of Geriatrics, The Second Xiangya Hospital of Central South University,
Changsha 410011, China.
E-mail addresses: 2446062816@qq.com (X.-Q. Wang), xiuhua203@csu.edu.cn,
2283375777@qq.com (X.-H. Wang).
related loss of skeletal muscle mass plus loss of muscle strength and/
or reduced physical performance. Currently, the prevalence of sarco-
penia in the Asian area ranges from 5.5% to 25.7%.3 With the accel-
eration of the aging society, more people will be at risk of sarcopenia.
There are no obvious symptoms of early sarcopenia, so patients
with sarcopenia are generally unaware of their sarcopenic state until
the gradual decline in physical performance becomes severe enough
to be pathological, resulting in physical and functional dependence.4,5
Therefore, population screening to detect sarcopenia before the
occurrence of physical disability is of great significance.6
The recommended criteria for the diagnosis of sarcopenia requires
the measurement of low muscle mass and either low muscle strength or
low physical performance.7 However, the feasibility of applying the
recommended diagnostic methods in the setting of population
screening is limited by the need for special muscle mass measurement

https://doi.org/10.1016/j.jamda.2020.05.041
1525-8610/Ó 2020 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
2 Y.-H. Mo et al. / JAMDA xxx (2020) 1e5
equipment and training.6 Hence, the 2019 Asian Working Group on
Sarcopenia in Older People (AWGS 2019) recommends strategies for
early identification of people with, or at risk for, sarcopenia to facilitate
necessary interventions in settings without advanced diagnostic
equipment.3
AWGS 2019 recommends using either calf circumference or the
strength, assistance in walking, rising from a chair, climbing stairs, and
falls (SARC-F) or SARC-F combined with calf circumference (SARC-CalF)
questionnaires for sarcopenia screening.3 Calf circumference has
moderate-to-high sensitivity and specificity in predicting sarcopenia or
low skeletal muscle mass.8e11 SARC-F was proposed in 2013 and its
validity has been tested in different populations.12e19 It exhibited very
good specificity to diagnose sarcopenia but low sensitivity.20 SARC-CalF
improved the sensitivity of SARC-F by adding calf circumference.13,17,21
The 2019 AWGS recommended the 3 sarcopenia screening methods in
primary health care or community preventive services settings for case-
finding. However, the consensus did not mention which of the 3
screening methods medical professionals should choose for community-
dwelling older persons of different genders, ages, and cognitive function.
Therefore, studies on comparing the screening ability and applicability of
the 3 sarcopenia screening methods are needed. At present, studies have
compared the accuracy of SARC-F and SARC-CalF in screening of sarco-
penia; however, no other studies have compared the accuracy of calf
circumference, SARC-F, and SARC-CalF in sarcopenia screening.
The objective of this study was to compare the ability and appli-
cability of calf circumference, SARC-F, and SARC-CalF for sarcopenia
screening in community-dwelling older adults.
Methods
Participants
From June to September 2019, we continuously recruited
community-dwelling older adults (60 years of age) in Changsha city,
Hunan, China. The exclusion criteria were individuals with the following
conditions: (1) electronic devices and metal implants are implanted; (2)
taking medications that affect body composition (eg, diuretics, gluco-
corticoids); (3) clinically visible edema; (4) physical and/or mental in-
capacity to perform the requested tests; and (5) unable to communicate
with interviewers. All participants (or their legal proxies) signed a
written informed consent form. Participant information was collected
through face-to-face interviews by trained researchers. The study pro-
tocol was approved by the Research Ethics Committee of our university.
Measurements
The calf circumference of all participants was measured when
participants sat with their legs relaxed and shoulder-width apart. Two
trained researchers used a millimeter graded tape to measure the
circumference of the thickest part of the right lower leg. As calf
circumference testers, they were blind to the results of sarcopenia
diagnostic by AWGS. The cutoff points to establish low muscle mass
from the calf circumference were <34 cm for men and <33 cm for
women according to 2019 AWGS criteria.3 Body height and weight
were measured using a stadiometer and a digital floor scale, respec-
tively. The body mass index was calculated using the following
equation: body mass index (kg/m2) ¼ body weight/height.2
The study participants answered a questionnaire regarding age,
SARC-F, education, and cognitive function. In this study, cognitive
function was evaluated by the Mini-Mental State Examination
(MMSE).22 Cognitive impairment was defined on the basis of the
education-adjusted cutoffs of MMSE scores: fewer than 16 points for
the illiterate, fewer than 21 points for those who had 6 years of edu-
cation or less, and fewer than 24 points for those who had more than
6 years of education.23
We used a bioimpedance analysis (BIA) device (Inbody S10;
Biospace, Seoul, Korea) to measure the appendicular skeletal muscle
index (SMI). A certain researcher was responsible for the measure-
ment of SMI, and the results were kept secret from other researchers.
Handgrip strength (HS) was measured using a digital hand dyna-
mometer (EH101; Xiangshan Inc, Guangdong, China). The dominant
hand was tested 2 times, and the higher value was recorded for the
analyses. A 6-m gait speed test was applied to evaluate physical per-
formance by asking participants to walk a 10-m course at their usual
gait; researchers recorded middle 6-m uniform pass time. A 6-m gait
speed is equal to 6 m divided by the recorded time. Walkers and canes
were accepted when walking, if necessary.
Diagnostic Criteria for Sarcopenia
As our participants were older Chinese adults, we used the 2019
AWGS criteria3 as the gold standard of sarcopenia. Diagnosis of sarco-
penia at the first level requires the measurement of gait speed and grip
strength. If gait speed or grip strength is reduced, the diagnosis needs
confirmation by muscle mass measurement.3 According to the recom-
mendation from the AWGS 2019, we defined low muscle strength as HS
< 28 kg for men and <18 kg for women. Low physical performance was
defined as gait speed <1.0 m/s. In addition, low muscle mass as SMI
<7.0 kg/m2 for men and <5.7 kg/m2 for women.
Next, as the 3 screening methods, the calf circumference, SARC-F, and
SARC-CalF questionnaires were used to estimate sarcopenia, respectively
(Supplementary Table 1). The measurement results of calf circumference
<34 cm for men and <33 cm for women indicated sarcopenia.3 A total
score of SARC-F 4 or SARC-CalF 11 indicated sarcopenia.3
Statistical Analyses
We compared the mean values of the characteristics of the par-
ticipants between non-sarcopenia and sarcopenia groups diagnosed
by AWGS 2019 criteria. For categorical variables, the data were pre-
sented as numbers (percentage). For continuous variables with
normal distribution or skewed distribution, the data were presented
as the mean (SD) or median (interquartile range), respectively. To
compare the differences between groups, the c2 test was used for
categorical data, 1-way analysis of variance was used for continuous
data with a normal distribution, and Mann-Whitney test was used for
continuous data with a skewed distribution.24
Using AWGS 2019 criteria as the reference standard, we calculated
the diagnostic value [sensitivity, specificity, positive likelihood ratio
(þLR), and negative likelihood ratio (LR)] of the calf circumference,
SARC-F, and SARC-CalF for identifying sarcopenia, respectively. The
performances of the screening methods were compared through
receiver operating characteristic (ROC) curve analysis, considering the
area under the ROC curves (AUCs) [with 95% confidence intervals (CIs)]
and Pearson c2 test for heterogeneity. The difference across ROC curves
was compared using the DeLong method.25 We also stratified the data by
gender, age, and cognitive function to explore the ability and applica-
bility of the 3 screening methods. Analyses were performed using the
statistical software program SPSS v 23.0 (IBM Corp, Armonk, NY) and
MedCalc v 15.2 (MedCalc Software bvba, Ostend, Belgium). All statistical
tests were 2-sided, and a P value of < .05 indicated statistical significance.
Results
Characteristics of Participants
The sample characteristics are demonstrated according to the AWGS
2019 criteria in Table 1. We included 347 men and 703 women in this
study. The mean age of the whole study population was 70.3  7.5 years.
Participants with sarcopenia were significantly older than those
 Y.-H. Mo et al. / JAMDA xxx (2020) 1e5 3

Table 1 Comparison of Accuracy of 3 Screening Methods

Characteristics of the Study Population According to the AWGS 2019 Sarcopenia
Criteria
Table 2 presents the results of sensitivity/specificity analyses
Characteristics AWGS 2019 Criteria Classification and AUCs of the calf circumference SARC-F and SARC-CalF both in
Non-Sarcopenia Sarcopenia P men and women when using the AWGS 2019 criteria as the gold
(n ¼ 787) (n ¼ 263) standard. The ROC curves of the 3 screening methods are shown in
Gender* Figure 1. In the total study participants, the calf circumference had
Men 263 (33.4) 84 (31.9) .705 a sensitivity of 81.4% (95% CI, 76.1e85.9) and a specificity of 77.0%
Women 524 (66.6) 179 (68.1) (95% CI, 73.9e79.9); the SARC-F had a sensitivity of 17.9% (95% CI,
Age*
13.4e23.0) and a specificity of 93.7% (95% CI, 91.7e95.2); and the
60e69 502 (63.8) 85 (32.3) <.001
70e79 237 (30.1) 117 (44.5) SARC-CalF had a sensitivity of 47.5% (95% CI, 41.4e53.8) and a
80 48 (6.1) 61 (23.2) specificity of 92.0% (95% CI, 89.8e93.8). The AUCs of calf circum-
Education* ference, SARC-F, and SARC-CalF were 0.79 (95% CI, 0.77e0.82), 0.56
Illiterate 179 (22.7) 83 (31.6) .002 (95% CI, 0.52e0.59), and 0.70 (95% CI, 0.67e0.73), respectively. The
6 y of education 226 (28.7) 82 (31.2)
differences across ROC curves were statistically significant among
>6 y of education 382 (48.5) 98 (37.3)
Cognitive impairment* 113 (14.4) 31 (11.8) .294 the 3 screening methods (P < .001). We found that the calf
Handgrip strength, kgy 22.7 (8.6) 16.2 (6.9) <.001 circumference shows the best sensitivity and AUC in screening
Gait speed, m/sy 1.0 (0.3) 0.8 (0.2) <.001 sarcopenia compared with SARC-F and SARC-CalF according to
CC, cmy 35.0 (2.7) 31.1 (2.5) <.001
AWGS 2019 criteria, whereas SARC-F and SARC-CalF had better
SARC-F scorez 0 (1.0) 1.0 (2.0) <.001
SARC-CalF scorez 0 (5.0) 10.0 (2.0) <.001
specificity than calf circumference. Similar results were found both
SARC-F classification* in men and women. The 3 screening methods in women showed
Non-sarcopenia 737 (93.6) 216 (82.1) <.001 higher sensitivity and AUC compared with men. The differences in
Sarcopenia 50 (6.4) 47 (17.9) AUC among calf circumference, SARC-F, and SARC-CalF were all
SARC-CalF classification*
statistically significant both in men and women (P < .001)
Non-sarcopenia 724 (92.0) 138 (52.5) <.001
Sarcopenia 63 (8.0) 125 (47.5) (Table 2).
Calf circumference classification* The screening abilities of the 3 screening methods in different age
Non-sarcopenia 606 (77.0) 49 (18.6) <.001 groups are shown in Table 3. The screening ability of the 3 screening
Sarcopenia 181 (23.0) 214 (81.4)
methods was higher in people aged 70 to 80 years than in those aged
BMI, body mass index; CC, calf circumference. 60 to 69 years and 80 years in general. Calf circumference had the
*Data are presented as n (%). best AUC and sensitivity in all age groups (AUC was 0.77 to 0.81,
y
Data are presented as the mean (SD).
z sensitivity was 77.7% to 86.9%) and the screening ability of calf
Data are presented as the median (interquartile range).
circumference was not significantly different among the 3 age groups.
without sarcopenia (P < .001). The educational level of non-sarcopenia SARC-CalF had moderate AUC and sensitivity when used in different
participants was significantly higher than that of sarcopenia partici- age groups. Also, the sensitivity increased and the specificity
pants (P ¼ .002). The mean calf circumference of sarcopenia participants decreased with age. The ROC analysis showed that SARC-F had very
was lower than non-sarcopenia participants (P < .001). The median low AUC (0.50 and 0.55) when used in community-dwelling older
scores of SARC-F and SARC-CalF were significantly different between adults aged 60 to 69 or older than 80 years (P ¼ .649 and P ¼ .091,
the sarcopenic and non-sarcopenic groups (P < .001). respectively).
Table 4 shows the screening ability of the 3 screening methods by
cognitive function. Compared with older adults with cognitive
Prevalence of Sarcopenia impairment, the screening ability of the 3 screening methods was
higher in older adults with normal cognitive function.
The prevalence of sarcopenia was 25.0% in our study population The AUC of 3 methods in normal cognitive participants was 0.56 to
using the AWGS 2019 criteria (men: 24.2%; women: 25.5%, P ¼ .705). 0.80, whereas in participants with cognitive impairment was 0.53 to
According to calf circumference, 37.6% of total study participants 0.75. Similarly, calf circumference had the best AUC and sensitivity in
(men: 34.6%; women: 39.1%, P ¼ .154) had sarcopenia. According to both cognitive function groups (AUC was 0.75 and 0.80, sensitivity was
SARC-F, 9.2% of participants (men: 6.6%; women: 10.5%, P ¼ .04) had 77.4% and 81.9%). In contrast, the sensitivities of SARC-F and SARC-CalF
sarcopenia. The SARC-CalF showed that the prevalence of sarcopenia significantly decreased when used in cognitively impaired participants,
was 17.9% (15.3% of men and 19.2% of women, P ¼ .118). going down from 18.5% to 12.9% and from 48.7% to 38.7%, respectively.

Table 2
Sensitivity/Specificity Analyses and ROC Models for Calf Circumference, SARC-F and SARC-CalF Validation Against the AWGS 2019 Criteria

Sensitivity,% Specificity,% þLR LR AUC P

Total
Calf circumference 81.4 (76.1e85.9) 77.0 (73.9e79.9) 3.5 (3.1e4.1) 0.2 (0.2e0.3) 0.79 (0.77e0.82) <.001
SARC-F 17.9 (13.4e23.0) 93.7 (91.7e95.2) 2.8 (1.9e4.1) 0.9 (0.8e0.9) 0.56 (0.52e0.59)
SARC-CalF 47.5 (41.4e53.8) 92.0 (89.8e93.8) 5.9 (4.5e7.8) 0.6 (0.5e0.6) 0.70 (0.67e0.73)
Men
Calf circumference 72.6 (61.8e81.8) 77.6 (72.0e82.5) 3.2 (2.5e4.2) 0.4 (0.2e0.5) 0.75 (0.69e0.81) <.001
SARC-F 11.9 (5.9e20.8) 95.1 (91.7e97.3) 2.4 (1.1e5.3) 0.9 (0.9e1.0) 0.54 (0.46e0.61)
SARC-CalF 36.9 (26.6e48.1) 91.6 (87.6e94.7) 4.4 (2.7e7.2) 0.7 (0.6e0.8) 0.64 (0.57e0.72)
Women
Calf circumference 85.5 (79.4e90.3) 76.7 (72.9e80.3) 3.7 (3.1e4.3) 0.2 (0.1e0.3) 0.81 (0.77e0.85) <.001
SARC-F 20.7 (15.0e27.3) 92.9 (90.4e95.0) 2.9 (1.9e4.5) 0.9 (0.8e0.9) 0.57 (0.53e0.61)
SARC-CalF 52.5 (44.9e60.0) 92.2 (89.5e94.3) 6.7 (4.8e9.3) 0.5 (0.4e9.3) 0.72 (0.69e0.76)

Values within parentheses are the 95% confidential intervals.

4 Y.-H. Mo et al. / JAMDA xxx (2020) 1e5

Fig. 1. The ROC curves of calf circumference, SARC-F, and SARC-CalF against the AWGS criteria in (A) the total study population; (B) men; and (C) women.

Moreover, in older adults with cognitive impairment, the AUC of SARC-F
was only 0.53 (P ¼ .187).
The þLR of the 3 screening tools were all higher than 1 and the LR
of the 3 screening tools were all lower than 1. The þLR of SARC-CalF
was the highest and the LR of calf circumference was the lowest
regardless of gender, age, and cognitive function.
Discussion
Our study compared the ability and applicability of calf circum-
ference, SARC-F, and SARC-CalF for sarcopenia screening among
community-dwelling older adults according AWGS 2019 criteria. To
our knowledge, at present, no other studies have compared the ac-
curacy of calf circumference, SARC-F, and SARC-CalF in screening of
sarcopenia. The results indicated that calf circumference was the best
among these 3 methods for screening sarcopenia regarding sensitivity
and AUC. In particular, the screening accuracy of calf circumference
was high regardless of gender, age, and cognitive function.
The review of epidemiology studies from Asian countries that used
AWGS 2014 criteria discovered that the prevalence of sarcopenia
ranged from 5.5% to 25.7%.3 In this study, the AWGS 2019 diagnostic
criteria were used. Compared with the AWGS 2014, the AWGS
2019 changed the cutoff points of walking speed (from 0.8 m/s to
<1.0 m/s) and male grip strength (from <26 kg to <28 kg). Despite
concerns that using BIA may reduce the prevalence of sarcopenia, with
the more stringent criteria, the prevalence of sarcopenia in our study
was relatively high at 25% (men: 24.2%; women: 25.5%).
Kawakami et al.8 found that calf circumference was positively
correlated with appendicular skeletal muscle mass and SMI. As muscle
mass is an indispensable index in the diagnosis of sarcopenia, calf
circumference has been applied to predict sarcopenia.8 Former
research regarding calf circumference in sarcopenia screening showed
that the sensitivity of calf circumference is 73% to 88%, specificity is
73% to 91%, and AUC is 0.79 to 0.94, indicating that the calf circum-
ference has good screening value for sarcopenia screening,8,9 which is
consistent with the results of our study. The recommended protocol
for calf circumference measures the maximal calf circumference using
a nonelastic tape. AWGS 2019 recommends calf circumference <34 cm
for men and <33 cm for women for sarcopenia screening.3 Calf
circumference is regarded as a reliable, time-saving, and easily
applicable screening method for sarcopenia.
SARC-F is a self-reported questionnaire assessing 5 components:
strength, assistance in walking, rising from a chair, climbing stairs, and
falls.12 SARC-F is a widely used screening method around the world. It
has been translated into Chinese,14 Korean,19 Japanese,16 and Spanish,15
and the effectiveness of screening for sarcopenia in different ethnic
populations has been verified.13e19 The results showed that its high
specificity was at the expense of low sensitivity. SARC-CalF improved
the sensitivity of SARC-F from low to moderate by adding the calf
circumference measurement.13,17,21 However, low-to-moderate sensi-
tivity is not adequate for wide population screening. In addition, as a
self- reported questionnaire, its screening accuracy can be interfered
with by the subjectivity and understanding ability of the respondents.
This study indicates that gender, age, and cognitive function can
affect the screening ability of SARC-F and SARC-CalF. It has been re-
ported that the SARC-F item pertaining to physical performance may
have been affected by gender differences, as men tend to choose re-
sponses that put their physical ability in a more favorable light,25,26
whereas women tend to choose responses that make them appear
needy of other’s care and protection. Therefore, it is not difficult to
understand the results in our study that the SARC-F and SARC-CalF in
women shows higher sensitivity and AUC compared with men. Be-
sides, age is an important influence on the screening ability of SARC-F
and SARC-CalF. Especially in older adults aged 60 to 79 years or older

Table 3
Sensitivity/Specificity Analyses and ROC Models for Calf Circumference, SARC-F and SARC-CalF Validation Against the AWGS 2019 Criteria in Different Age Groups

Sensitivity,% Specificity,% þ LR LR AUC P

60e69 y old
Calf circumference 77.7 (67.3e86.0) 76.7 (72.7e80.3) 3.3 (2.7e4.1) 0.3 (0.2e0.4) 0.77 (0.74e0.81) <.001
SARC-F 2.4 (0.3e8.2) 96.8 (94.9e98.2) 1.0 (0.9e1.0) 0.7 (0.2e3.2) 0.50 (0.43e0.56) .649
SARC-CalF 35.3 (75.7e85.4) 93.4 (90.9e95.4) 5.4 (3.5e8.3) 0.7 (0.6e0.8) 0.64 (0.60e0.68) <.001
70e79 y old
Calf circumference 81.2 (72.9e87.8) 80.2 (74.5e85.0) 4.1 (3.1e5.4) 0.2 (0.2e0.3) 0.81 (0.76e0.85) <.001
SARC-F 18.8 (12.2e27.1) 90.3 (85.8e93.7) 1.9 (1.1e3.3) 0.9 (0.8e1.0) 0.57 (0.49e0.60) .027
SARC-CalF 47.0 (37.7e56.5) 92.4 (88.3e95.4) 6.2 (3.8e10.0) 0.6 (0.5e0.7) 0.70 (0.65e0.75) <.001
80 y old
Calf circumference 86.9 (75.8e94.2) 64.6 (49.5e77.8) 2.5 (1.7e3.6) 0.2 (0.1e0.4) 0.76 (0.67e0.83) <.001
SARC-F 37.7 (25.6e51.0) 77.1 (62.7e88.0) 1.7 (0.9e3.0) 0.8 (0.6e1.0) 0.55 (0.48e0.67) .091
SARC-CalF 65.6 (52.3e77.3) 75.0 (60.4e86.4) 2.6 (1.6e4.4) 0.5 (0.3e0.7) 0.70 (0.61e0.79) <.001

Values within parentheses are the 95% confidential intervals.

 Y.-H. Mo et al. / JAMDA xxx (2020) 1e5
Table 4
Sensitivity/Specificity Analyses and ROC Models for Calf Circumference, SARC-F and SARC-CalF Validation Against the AWGS 2019 Criteria in Different Cognitive Function
Groups
Sensitivity,% Specificity,%
Normal cognitive
Calf circumference 81.9 (76.3e86.6) 77.6 (74.3e80.7)
SARC-F 18.5 (13.8e24.1) 93.3 (91.2e95.1)
SARC-CalF 48.7 (42.1e55.3) 91.5 (89.2e93.5)
Cognitive impairment
Calf circumference 77.4 (58.9e90.4) 73.5 (64.3e81.3)
SARC-F 12.9 (3.6e29.8) 95.6 (90.0e98.5)
SARC-CalF 38.7 (21.8e57.8) 94.7 (88.8e98.0)
Values within parentheses are the 95% confidential intervals.
than 80 years, the AUC of SARC-F was extremely low. The ROC analysis
showed that SARC-F is not suitable for use in community-dwelling
older adults aged 60 to 69 or older than 80 years. This may lead to a
significant reduction in the scope of application of SARC-F. Further-
more, when using the SARC-F questionnaire for screening in older
adults, it requires good ability of understanding and expression, which
leads to the reduced applicability of SARC-F and SARC-CalF in older
adults with impaired cognitive function. Hence, the sensitivities and
AUCs of SARC-F and SARC-CalF are lower when used in participants
with cognitive impairment compared with those with normal cogni-
tive function. The ROC analysis results indicated that the SARC-F is not
applicable for screening sarcopenia in older adults with cognitive
impairment. Therefore, cognitive function evaluation is needed before
using SARC-F in screening for sarcopenia.
Some limitations of our study need to be addressed. First, this study
focused only on community-dwelling older adults who were living
independently or needed little help, and did not include adults living in
nursing homes. Hence, the results in this study are not applicable for
nursing homeedwelling older adults. Second, our study is a cross-
sectional design and compared only the diagnostic value of the 3
screening methods for identifying sarcopenia in the community. These
3 methods were also recommended by AWGS 2019 for use in health
care or clinical research settings. Because the prevalence and physical
condition of sarcopenia are different in older adults living in different
places, the screening ability and applicability of the 3 methods may be
different. Further studies are needed to compare the value of these
methods in different settings. Last, the individuals taking medications,
such as diuretics and glucocorticoids, and those with clinically visible
edema were excluded from the analysis. However, the usage of these
drugs and the presence of edema are common among community-
dwelling older adults, therefore, selection bias might be induced.
Conclusions and Implications
The overall screening of calf circumference was better than that of
SARC-F and SARC-CalF despite gender, age, and cognitive function.
SARC-F and SARC-CalF have high specificity but are susceptible to the
preceding factors. Further studies are needed to compare the ability
and applicability of these screening methods in different settings.
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5.e1 Y.-H. Mo et al. / JAMDA xxx (2020) 1e5

Supplementary Table 1
The SARC-F and SARC-CalF Questionnaire

Components Questions SARC-F Score SARC-CalF Score

Strength How much difficulty do you have in lifting and carrying 10 pounds? None ¼ 0 None ¼ 0
Some ¼ 1 Some ¼ 1
A lot or unable ¼ 2 A lot or unable ¼ 2
Assistance in walking How much difficulty do you have walking across a room? None ¼ 0 None ¼ 0
Some ¼ 1 Some ¼ 1
A lot, use aids, or unable ¼ 2 A lot, use aids, or unable ¼ 2
Rise from a chair How much difficulty do you have transferring from a chair or bed? None ¼ 0 None ¼ 0
Some ¼ 1 Some ¼ 1
A lot or unable without help ¼ 2 A lot or unable without help ¼ 2
Climb stairs How much difficulty do you have climbing a flight of 10 stairs? None ¼ 0 None ¼ 0
Some ¼ 1 Some ¼ 1
A lot or unable ¼ 2 A lot or unable ¼ 2
Falls How many times have you fallen in the past year? None ¼ 0 None ¼ 0
1e3 falls ¼ 1 1e3 falls ¼ 1
4 or more falls ¼ 2 4 or more falls ¼ 2
Calf circumference Women:
33cm ¼ 0
<33cm ¼ 10
Men:
34cm ¼ 0
<34cm ¼10