Geriatric Nursing 49 (2023) 157 163

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Geriatric Nursing
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Featured Article

Comparison of four screening methods for sarcopenia among

community-dwelling older adults: A diagnostic accuracy study
Ya-Huang Lin, MSN, RNa, Kwo-Chen Lee, PhD, RNb,c, Ya-Ling Tzeng, PhD, RNb,c,
Yun-Ping Lin, PhD, RNb,c,*, Wen-Miao Liu, PhD, RNd, Shu-Hua Lu, PhD, RNb,c,*
a
Department of Nursing, Min-Hwei Junior College of Health Care Management, Tainan, Taiwan
b
School of Nursing, China Medical University, Taichung, Taiwan
c
Department of Nursing, China Medical University Hospital, Taichung, Taiwan
d
Department of Nursing, Central Taiwan University of Science and Technology, Taichung, Taiwan

A R T I C L E I N F O A B S T R A C T

Article history: This study aimed to compare the diagnostic values of SARC-F (strength, assistance with walking, rising from a
Received 10 August 2022 chair, climbing stairs, and falls), SARC-Calf (SARC-F combined with calf circumference), CC (calf circumfer-
Received in revised form 7 December 2022 ence), and the Yubi-wakka (finger-ring) test for screening for sarcopenia in community-dwelling older
Accepted 7 December 2022
adults. The Asian Working Group for Sarcopenia (AWGS) 2019 criteria were used as a standard reference. A
Available online 19 December 2022
total of 209 participants were enrolled, and 40.7% were identified as sarcopenia. The sensitivity, specificity,
and AUC were respectively 54.1%, 70.2%, and 0.687 for SARC-F; 76.5%, 73.4% and 0.832 for SARC-calf, 86.7%,
Keywords:
82.4%, and 0.906 for CC in men, and 85.5%, 63.3%, and 0.877 for CC in women. Relative to the “bigger,” a sig-
Calf circumference
Sarcopenia
nificant association between sarcopenia and the Yubi-wakka test (“just fits” OR: 4.1, 95% CI: 1.57 10.98;
SARC-F “small” OR: 27.5, 95% CI: 10.14 74.55) was observed. The overall accuracy of CC was better than SARC-Calf
SARC-Calf for sarcopenia screening.
Yubi-wakka (finger-ring) test © 2022 Elsevier Inc. All rights reserved.

Introduction and notably, increased mortality.9 A systematic review showed a

The Asian Working Group for Sarcopenia (AWGS) 2014 consensus
defines sarcopenia as “age-related loss of muscle mass, plus low mus-
cle strength, and/or low physical performance”.1 Sarcopenia is one of
the primary causes of frailty in older adults.2-4 Sarcopenia and frailty
are frequently used as synonyms in older adults,2 but muscle mass
and strength decline in older adults for various reasons. Aging can
lead to changes in metabolism and the function of the endocrine and
nervous systems, affecting muscle mass and muscle strength. Aging
is also associated with certain negative lifestyles, physical inactivity,
poor nutritional and dental status, and chronic diseases (e.g., osteo-
porosis, metabolic disease, etc.).4
According to the AWGS’s criteria, sarcopenia has a prevalence of
approximately 50.9% in daycare centers,5 of 36.4% in those living in
long-term care,6 of 10% in community-dwelling outpatients,7 and of
9.3% in male and 4.1% in female community-dwelling older adults.8
Sarcopenia is also associated with adverse health outcomes, including
physical disability, falling, fractures, hospitalization, depression, poor
quality of life, increased health care costs, adverse metabolic effects,
*Corresponding author at: School of Nursing, China Medical University, 100, Sec. 1,
Jingmao Rd., Taichung 406040, Taiwan.
E-mail addresses: yunping@mail.cmu.edu.tw (Y.-P. Lin), shuhua@mail.cmu.edu.tw
(S.-H. Lu).
higher rate of mortality among patients with sarcopenia (pooled OR:
3.596, 95% CI: 2.96 4.37), an association with functional decline
(pooled OR: 3.03, 95% CI: 1.80 5.12), a higher rate of falls, and a
higher incidence of hospitalization.10
Early detection of sarcopenia and early intervention are
important to improve muscle function. Resistance exercise and
nutritional supplementation have been shown to effectively
improve muscle strength.11 A meta-analysis showed that resis-
tance training for hand grip strength, lower-limb strength, agility,
gait speed, postural stability, functional performance, lowered fat
mass, and increased muscle mass during the early stages of sarco-
penia had positive effects and attenuated the negative effects of
sarcopenia and decreased frailty.12
Sarcopenia is one of the most important health issues affecting
older adults, and health professionals must be aware of the risks of
developing sarcopenia. Screening and diagnosis are key to disease
prevention and monitoring. Screening is aimed at detecting potential
diseases in asymptomatic but high-risk groups,13 with a focus on
early detection and monitoring the potential risk of developing those
diseases.14 Diagnosis is used to establish the presence or absence of
the disease in those who may be symptomatic or asymptomatic but
have a positive screening test.15

https://doi.org/10.1016/j.gerinurse.2022.12.007
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158 Y.-H. Lin et al. / Geriatric Nursing 49 (2023) 157 163
The diagnostic instruments for measuring muscle mass include
CT, MRI, and DEX.9 Although these three measurements are relatively
accurate, they are expensive. Another commonly used diagnostic
method is bioelectrical impedance analysis (BIA), which is technically
challenging and may not be readily accessible.16,17 Therefore, finding
simple, fast, and reliable screening tools is imperative.
Existing screening tools include the SARC-F (strength, assistance
with walking, rising from a chair, climbing stairs, and falls),18 SARC-
Calf (SARC-F combined with calf circumference) test,19 calf circumfer-
ence (CC),20 Yubi-wakka (finger ring) test,21 MSRA-5 and -7 (Mini
Sarcopenia Risk Assessment)22 and Ishii test.23 In 2019, the AWGS24
recommended the use of SARC-F,18 SARC-Calf,19 and CC20 as primary
screening tools for sarcopenia. However, the validity of these tools
has not been tested in Taiwan. An alternative is the Yubi-wakka (fin-
ger-ring) test,21 which is a simple, convenient, and fast self-screening
method that does not require professional assistance.
The purpose of this study is to compare the validity of SARC-F,18
SARC-Calf,19 CC,20 and Yubi-wakka (finger-ring)21 test for sarcopenia
screening among community-dwelling older adults to find suitable
sarcopenia screening tools, specifically for the community of Taiwan,
to enable the early detection of sarcopenia and allow for the timely
implementation of preventive intervention to reduce the threat of
disability and improve the quality of life.
Methods
Study design and population
We conducted a diagnostic accuracy cross-sectional study to
examine the psychometric properties of four screening tools. During
October and November 2020, we used continuous purposive sam-
pling to recruit older adults dwelling in the Mailiao community in
Yunlin City, Taiwan. Participants over 65 years of age and who could
communicate with each other were included in this study. The exclu-
sion criteria were: (1) physical and/or mental incapacity to perform
requested assessments, such as being bedridden or at the end of life,
severe dementia, or being unable to walk independently; (2) contra-
indications for BIA, such as having a pacemaker or implanted
electronic device; (3) presence of factors affecting the accuracy
of CC measurement and finger ring test, such as clinically visible
lower extremity edema.
Research ethics
The study protocol was approved by the Research Ethics Commit-
tee of China Medical University (CRREC-109-133), who also autho-
rized a waiver of written informed consent for the participants.
Participant information was collected through personal interviews
with the primary researcher (Ya-Huang Lin).
Assessment of sarcopenia using AWGS criteria
We used the AWGS 2019 criteria as the standard reference for
the diagnosis of sarcopenia. The detailed criteria are: (1) muscle
mass < 7.0 kg/m2 for men, < 5.7 kg/m2 for women; (2) grip strength
< 28 kg for men, < 18 kg for women; and (3) gait speed for a 6-meter
walk < 1.0 m/s.
SARC-F
The SARC-F questionnaire was developed by Malmstrom et al.
(2013)18 in the United States. It assesses five components: “Strength,
how much difficulty do you have in lifting and carrying 10 lb. (None = 0;
Some = 1; A lot or unable =2); assistance in walking, how much difficulty
do you have walking across a room (none = 0; some = 1; a lot, use aids,
or unable = 2); rise from a chair, how much difficulty do you have trans-
ferring from a chair or bed (none = 0; some = 1; a lot or unable without
help = 2); climb stairs, how much difficulty do you have climbing a flight
of 10 stairs (none = 0; some = 1; a lot or unable = 2); falls, how many
times have you fallen in the past year (none = 0; 1 3 falls = 1;
4
falls = 2)” (P. 631).25 Scores range from 0 to 10; a total score higher
than 4 is considered as having sarcopenia. The SARC-F has a sensitiv-
ity, specificity, and AUC of 3.8-9.9%, 94.2-99.1%, and 0.78-0.9,
respectively.25
SARC-Calf
The SARC-Calf questionnaire was developed by Barbosa-Silva et
al.19 in Brazil. It improved the sensitivity of SARC-F by adding the CC
measurement. Scores are computed as SARC-F score plus an addi-
tional value based on CC, with CC in females > 33 cm = 0 and  33
cm = 10, and CC in males > 34 cm = 0 and  34 cm = 10. The total
score ranges from 0 to 20, with a score
11 suggestive of sarcopenia.
SARC-Calf has a sensitivity, specificity, and AUC of 66.7%, 82.9%, and
0.736, respectively.19
Calf circumference (CC)
Kawakami et al.20 designed the CC measurement in Japan as a
marker for muscle mass. The CC is measured to the nearest 0.1 cm
with the patient in a standing position using a non-elastic tape mea-
sure. The tape measure is placed around the calf without putting
pressure on the subcutaneous tissue and is moved along the length
of the calf to obtain the maximum circumference. The average of two
CC measurements for each leg was recorded, and these values were
averaged again over both legs for the final value. The cut-off values
for predicting sarcopenia from CC measurements were 34 cm in men
(AUC 0.94, sensitivity 88%, specificity 91%) and 33 cm in women (AUC
0.84, sensitivity 76%, specificity 73%).20
Yubi-wakka (finger ring) test
Tanaka et al.21 developed a simple self-screening method in Japan.
The finger ring test uses the ring circumference formed by the thumb
and index finger of both hands to evaluate whether the circumfer-
ence of the calf is larger than the circumference of the fingers. The
evaluation results are divided into three categories: (1) “bigger”
refers to the calf being bigger than the finger ring, indicating the ring
cannot be closed; (2) “just fits” refers to the calf and finger ring being
about the same size; and (3) “smaller” refers to the calf being smaller
than the finger ring, creating a gap. “Just fits” and “smaller” indicate a
risk of developing sarcopenia.21
Relative to the “bigger” group, community-dwelling older adults
in the “just fits” and the “smaller” groups were found to be associated
with sarcopenia (“just fits” OR: 2.4, 95% CI: 1.4 4.1 and “smaller” OR:
6.6, 95% CI: 3.5 13) by multivariate analyses.21
Anthropometric measurement
We used a BIA device (Inbody 270; Biospace, Seoul, Korea) to
measure appendicular skeletal muscle mass (ASM) and body fat
mass. During the measurement, participants were asked to stand
with their feet in firm contact with the electrodes at the front and
back of their foot and to grip an electrode in each hand so that the
palms and thumbs were in complete contact with it. The ASM refers
to the sum of skeletal muscle masses of the four limbs. The skeletal
muscle index (SMI) was calculated as ASM/height (kg/m2).24,26
 Y.-H. Lin et al. / Geriatric Nursing 49 (2023) 157 163 159

Muscle strength Table 1

Demographic characteristics of the study population according to the AWGS 2019 sar-
copenia criteria (N=209)
The AWGS 201924 recommends using handgrip strength to mea-
sure muscle strength. The present study measured handgrip strength Characteristics Total Men Women t /x2 pa
using a hydraulic hand dynamometer (Jamar-5030J; JLM Instrument (n = 209) (n = 64) (n = 145)
Company, Chicago, USA). During the measurement, the participants Age (years) 77.7 (7.2) 77.2 (8.0) 78 (6.9) .761 .084
were asked to sit upright in a chair with back support, with elbows Chronic disease
bent 90 degrees and forearms and wrists in a neutral position with Hypertension 121 (57.9) 38 (59.4) 83 (57.2) .083 .773
Diabetes 69 (33.0) 17 (26.6) 52 (35.9) 1.736 .188
their thumbs facing up, with elbows unsupported. The test was
CHD 61 (29.2) 18 (28.1) 43 (29.7) .50 .823
started by squeezing the handle with maximum force for 3-5 seconds Osteoporosis 54 (25.8) 11 (17.2) 43 (29.7) 3.602 .058
with the dominant hand twice, with a 60-second pause. The highest COPD 4 (1.9) 3 (4.7) 1 (0.7) 3.780 .052
value was recorded for analysis.27,28 AWGS criteria
CC (cm) 33 (3.3) 34 (2.8) 32.5 (3.4) 2.92 .091
GS (m/s) 0.7 (0.3) 0.8 (0.2) 0.7 (0.2) 3.28 .484
Physical performance
HS (kg) 22.6 (8.0) 29.7 (8.0) 19.4 (5.6) 10.58 .033*
ASM (kg) 15.1 (3.6) 18.7 (3.1) 13.5 (2.5) 13.01 .039*
The AWGS 201924 consensus recommends using usual gait speed AWGS Classification
to measure physical performance. The timing starts from the begin- Non-sarcopenia 124 (59.3) 34 (53.1) 90 (62.1) 1.472 .225
ning of the first step and ends when their feet completely cross the Sarcopenia 85 (40.7) 30 (46.9) 55 (37.9)
SARC-F Classification
endpoint. The time it takes for the patient to walk six meters is mea- Non-sarcopenia (0 3) 125 (59.8) 51 (79.7) 74 (51) 15.165 <.001***
sured. The test was done twice, and the best time was recorded for Sarcopenia (
4) 84 (40.2) 13 (20.3) 71 (49)
the analysis. Sarcopenia is indicated at a six-meter gait speed of SARC-Calf Classification
< 1.0 m/s.24,29,30 Non-sarcopenia (0 10) 107 (51.2) 42 (65.6) 65 (44.8) 7.687 .006**
Sarcopenia (
11) 102 (48.8) 22 (34.4) 80 (55.2)
CC Classification (cm)
Statistical analysis Non-sarcopenia 92 (44) 34 (53.1) 58 (40) 3.104 .078
Sarcopenia ( 34 /  33) 117 (56) 30 (46.9) 87 (60)
Analyses were performed using the statistical software SPSS v Yubi-wakka Classification
23.0 (IBM, Armonk, NY). Using the AWGS 2019 criteria as the refer- Non-sarcopenia (bigger) 61 (29.2) 16 (25) 45 (31) .782 .376
Sarcopenia (just fits + smaller) 148 (70.8) 48 (75) 100 (69)
ence standard, we calculated the required diagnostic values (sensitiv-
ity and specificity) for identifying sarcopenia according to SARC-F, Abbreviations: CHD: coronary heart disease; COPD: chronic obstructive pulmonary
disease; CC: calf circumference; GS: gait speed; HS: handgrip strength; ASM: appendic-
SARC-Calf, and CC, respectively. ular skeletal muscle mass. AWGS: Asian Working Group for Sarcopenia; SARC-F:
In addition, we used a receiver operating characteristics (ROC) strength, assistance with walking, rising from a chair, climbing stairs, and falls; SARC-
curve to compare the overall accuracy of the three metrics. The area Calf: SARC-F combined with calf circumference.
a
under the ROC curve (AUC) and 95% confidence interval (CI) were cal- p -values were generated from t-test or chi-square test.
* p < .05.
culated, with a larger AUC indicating better overall diagnostic accu-
** p < .01.
racy. Generally, an AUC of > 0.9 indicates high accuracy, 0.7-0.9 *** p < .001.
indicates moderate accuracy, 0.5-0.7 indicates low accuracy, and 0.5
indicates random results.31
To assess the effectiveness of the Yubi-wakka (finger-ring) test, 145, 60%); and based on Yubi-wakka, 70.8% (148/209) of participants
we used binary logistic regression to predict the risk of sarcopenia had sarcopenia (men: 48/64, 75%; women: 100/145, 69%) (Table 1).
and set the “large” category as the reference group. A larger OR value
indicates a stronger correlation, thus 1 means no correlation, > 1 SARC-F
means positive correlation, and < 1 means negative correlation.32
The AUC for SARC-F was measured at 0.687 (95% CI: 0.614 0.760)
Results (Fig. 1), with a sensitivity and specificity of 54.1% and 70.2%, respec-
tively, for the total cohort. The AUC was 0.775 (95% CI: 0.695 0.855)
Demographic characteristics of participants in men (Fig. 1), and the sensitivity and specificity were 32.9% and
95.2%, respectively, whereas AUC was 0.704 (95% CI: 0.619 0.789) in
We included 209 participants in this study, 64 (30.6%) men and women (Fig. 1), and the sensitivity and specificity were 65.5% and
145 (69.4%) women. The mean age of the entire cohort was 77.7 § 61.1%, respectively (Table 2).
7.2 years. There was no significant difference in age between male
and female participants (77.2 vs. 78.0 years, p = 0.084). Compared
with women, men had significantly larger CC, handgrip strength, gait SARC-Calf
speed, and skeletal muscle mass. The measurements of handgrip
strength (p = 0.033) and skeletal muscle mass (p = 0.039) were signifi- For SARC-Calf, the AUC was measured at 0.832 (95% CI:
cantly different between genders (Table 1). 0.778 0.887) (Fig. 1), with a sensitivity and specificity of 76.5% and
73.4%, respectively, for the total cohort. For men, the AUC was 0.941
Prevalence of sarcopenia (95% CI: 0.903 0.978) (Fig. 1), and the sensitivity and specificity
were 69.9% and 96.7% respectively. For women, the AUC was 0.824
For our study population, the prevalence of sarcopenia was 40.7% (95% CI: 0.756 0.891) (Fig. 1), and the sensitivity and specificity
(85/209) using the AWGS 2019 criteria (men: 30/64, 46.9%; women: were 83.6% and 65.6%, respectively (Table 2).
55/145, 37.9%). Based on the SARC-F results, 40.2% (84/209) of partici-
pants had sarcopenia (men: 13/64, 20.3%; women: 71/145, 48.9%); Calf circumference (CC)
based on SARC-Calf, 48.8% (102/209) of participants had sarcopenia
(men: 22/64, 34.4%; women: 80/145, 55.2%); based on CC, 56% (117/ For CC, the AUC was 0.906 (95% CI: 0.827 0.986) (Fig. 2), with a
209) of participants had sarcopenia (men: 30/64, 46.9%; women: 87/ sensitivity and specificity of 86.7% and 82.4% respectively, in men;
160 Y.-H. Lin et al. / Geriatric Nursing 49 (2023) 157 163

Fig 1. The ROC curves of SARC-F, and SARC-Calf against the AWGS criteria in total study populations (A), men (B) and women (C).

and an AUC of 0.877 (95% CI: 0.819 0.935) (Fig. 2), with a sensitiv- Discussion
ity and specificity of 85.5% and 63.6%, respectively, in women
(Table 2). This study evaluated SARC-F, SARC-Calf, CC, and the Yubi-wakka
(finger-ring) test as screening tools for sarcopenia using the AWGS
2019 consensus as the diagnostic criteria. The results showed that
Yubi-wakka (finger ring) test the AUC derived from CC showed less variation (AUC: 0.877 0.906)
(stable) in the total cohort, males, and females, and was less affected
For the Yubi-wakka (finger-ring) test, we used binary logistic by gender compared to the other metrics, with acceptable discrimi-
regression to analyze the risk of developing sarcopenia. Setting “big- nation. In addition, CC had the best sensitivity and AUC for screening
ger” as the reference group, the test results are statistically associated for sarcopenia compared with SARC-F and SARC-Calf, according to
with the presence of sarcopenia (“just fits” OR: 4.1, 95% CI: the AWGS 2019 criteria.
1.57 10.98; “small” OR: 27.5, 95% CI: 10.14 74.55) for the total The second-best metric was SARC-Calf (AUC: 0.824 0.941), which
cohort. Sixty (28.7%) participants were in the “bigger” group, 76 showed a difference between men and women (AUC: 0.941 vs.
(36.3%) in the “just fits” group, and 73 (34.9%) in the “smaller” group 0.824). The Yubi-wakka (finger-ring) test results were analyzed using
(Table 3). binary logistic regression with the “bigger” group as the reference
Among men, 15 (23.47%) were in the “bigger” group, 27 (42.18%) group, and the results showed that the “smaller” and “just fits”
in the “just fits” group, and 22 in the “smaller” group (34.37%). These groups were associated with sarcopenia. However, the “just fits”
assessments are statistically associated with the presence of sarcope- group of men was not significantly associated with sarcopenia.
nia (“just fits” OR: 2.7, 95% CI: 0.69 10.89 and “small” OR 10.6, 95% The results of our study are the same as those of Kim and Won33
CI: 2.69 42.24). Among women, 45 (31.03%) were in the “bigger” and Mo et al.34 both showing that CC prediction (AUC: 0.64, 0.79) out-
group, 49 (33.79%) in the “just fits” group, and 51 in the “smaller” performed SARC-Calf (AUC: 0.62, 0.70) and SARC-F (AUC: 0.51, 0.56).
group (35.17%). These assessments are also statistically associated Participants in a study by Lin et al.35 were peritoneal dialysis patients
with the presence of sarcopenia (“just fits” OR: 5.0, 95% CI: (mean age = 57.5 § 14.1 years), and also had CC values (AUC: 0.813)
1.33 19.15 and “small” OR 45.5, 95% CI: 11.93 173.4) (Table 3). better than SARC-Calf (AUC: 0.739) and SARC-F (AUC: 0.587). The
above studies and the results of the present study all showed that CC
has a good ability to predict sarcopenia, whether it is in older adults
in the community or middle-aged people on peritoneal dialysis.
Table 2
Lin et al.36 used the Ishii test, CC, SARC-F, and SARC-Calf for the
Sensitivity and specificity analyses, and ROC models for SARC-F, SARC-Calf and Calf cir-
cumference validation against the AWGS 2019 criteria (N=209).
assessment of sarcopenia in older adults in nursing homes. The
results showed that the Ishii test (AUC: 0.86) performed better than
Sensitivity Specificity AUC 95% CI CC (AUC: 0.67). In contrast to our study, the Ishii test23 covering age,
SARC-F (
4) CC, and grip strength may be better at predicting sarcopenia in nurs-
Total (84/209) 54.1% 70.2% 0.687 0.614 0.760 ing home residents than using CC alone, because the health and func-
Men (13/64) 32.9% 95.2% 0.775 0.695 0.855 tional status of such patients are different from those of older adults
Women (71/145) 65.5% 61.1% 0.704 0.619 0.789
in the community.
SARC-Calf (
11)
Total (102/209) 76.5% 73.4% 0.832 0.778 0.887 The AUC of SARC-F in our study was 0.687 0.775. The metric’s
Men (22/64) 69.9% 96.7% 0.941 0.903 0.978 sensitivity was low for the total population, males, and females.
Women (80/145) 83.6% 65.6% 0.824 0.756 0.891 These results are similar to those of previous studies, which also used
Calf circumference AWGS diagnostic criteria for sarcopenia. Woo et al.25 reported a sen-
Men (30/64) 86.7% 82.4% 0.906 0.827 0.986
Women (87/145) 85.5% 63.3% 0.877 0.819 0.935
sitivity of 4.8 9.4%; Kim et al.37 reported 24%, and Parra-Rodríguez et
al.38 reported 31.5% (all three studies used community-dwelling
Abbreviations: SARC-F: strength, assistance with walking, rising from a chair, climbing
stairs, and falls; SARC-Calf: SARC-F combined with calf circumference; ROC models:
older adults). A meta-analysis by Voelker et al.39 also showed low to
Receiver Operating Curve Model; AUC: The area under the ROC curve; 95% CI: 95% Con- moderate sensitivity (28.9% 55.3%) and moderate to high specificity
fidence Interval. (68.9% 88.9%), suggesting that this test should not be a priority for
 Y.-H. Lin et al. / Geriatric Nursing 49 (2023) 157 163 161

Fig 2. The ROC curves of calf circumference against the AWGS criteria in men (A) and women (B).

use in sarcopenia screening. With respect to analysis by gender, we
found a lower sensitivity and higher specificity for males, similar to
the previous results by Woo et al.25 This may be due to the self-
reported questionnaire, where men may tend to overestimate their
physical performance, while women may tend to underestimate it.40
The AUC of SARC-Calf was 0.824 0.941, which agrees with
previous studies where adding CC improved overall measurement
accuracy, sensitivity, and specificity.41 Similar results were
obtained in the past when AWGS was used as the standard for
diagnosing sarcopenia. For example, Yang et al.41 found a sensi-
tivity of 60.7% and a specificity of 94.7%; Urzi et al.42 found a sen-
sitivity of 77.4% and a specificity of 89.8%. However, as with
SARC-F, sensitivity in men was lower than in women (69.9% vs.
83.6%), similar to the results from Yang et al.41 In contrast to our
findings, Ishimoto et al.43 suggested that reducing the SARC-Calf
cut-off score from 11 to 7 could improve sensitivity (76.3% vs.
94.7%) and specificity (100% vs. 92.3%). This reduced cut-off may
be more useful in screening sarcopenia.
According to AWGS 2019 diagnostic criteria and the original study
by Kawakami et al.20 the cut-off values recommended for the CC test
are
34 cm in males and
33 cm in females. Using these cut-off val-
ues, we found an AUC of 0.877 0.906 for both genders, suggesting
excellent detection capacity.31 Kim et al.44 proposed CC as a substi-
tute for the DXA muscle mass measure that can reflect lower extrem-
ity muscle mass. Our results are similar to those of the original study
for both genders (AUC: 0.94 in men, 0.84 in women),20 showing that
these cut-off values apply to both groups of participants. A study by
Borges et al.45 used CC to predict sarcopenia in hospitalized older
adults with hip fractures in Spain using the European Working Group
on Sarcopenia in Older People (EWGSOP2) diagnostic criteria. The
demonstrated capacity of CC to predict sarcopenia (AUC: 0.82) agree
with these findings despite the differences in study participants and
diagnostic criteria.
We suggest that the original cut-off values for the CC method are
applicable since the original Japanese study population20 and our
Taiwanese study population had similar racial characteristics. How-
ever, results from the Korean Frailty and Aging Cohort Study (KFACS)
by Kim et al.44 indicated optimal cut-off values of CC for low muscle
mass of 35 cm (AUC: 0.81) for males and 33 cm (AUC: 0.72) for
females. Although Kim et al.’s study used the same diagnostic criteria
for sarcopenia, the optimal cut-off point for men was different from
ours. Cut-off values may need to be further varied to determine the
most suitable thresholds for different situations. In future studies, the
research population should be expanded to include people from dif-
ferent countries and clinical settings, e.g., long-term care institutions
and hospitalized older adults, to confirm whether the cut-off value
needs to be adjusted. Alternatively, the Youden’s index46 could be
used to find the best cut-off values in different situations.
The CC can reflect the muscle mass of lower extremities. The
actual finger ring size used in the Yubi-wakka (finger-ring) test (on
average, 33 cm for males and 31 cm for females) is similar to a rough
CC measurement.21 Our results showed that the proportion of “just
fits” and “smaller” outcomes in the Yubi-wakka (finger-ring) test was
about 53% (79/149) in older adults with sarcopenia, consistent with
the study by Nishikawa et al.47 which showed that the proportions of
sarcopenia in patients with bigger, just fits, and smaller outcomes
were 3.5% (5/142), 18.2% (6/33), and 33.3% (9/27), respectively.
Although their study participants and diagnostic criteria of

Table 3
Binary logistic regression analysis: association between sarcopenia and the “Yubi-wakka” test (N=209).

Overall Men (n = 64) Women (n = 145)

n OR 95% CI p n OR 95% CI p n OR 95% CI p

Yubi-wakka
Bigger 6/60 1.00 Reference 3/15 1.00 Reference 3/45 1.00 Reference
Just fits 24/76 4.1 1.57 10.98 .004** 11/27 2.7 0.69 10.89 .150 13/49 5.0 1.33 19.15 .017**
Smaller 55/73 27.5 10.14 74.55 <.001*** 16/22 10.6 2.69 42.24 < .001*** 39/51 45.5 11.93 173.4 <.001***
Abbreviations: 95% CI: 95% Confidence Interval; OR, odds ratio.
* p < .05.
** p < .01.
*** p < .001.
162 Y.-H. Lin et al. / Geriatric Nursing 49 (2023) 157 163
sarcopenia were different from our study, the proportion of sarcope-
nia detected with the Yubi-wakka (finger-ring) test was similar.
Additionally, the “just fits” group had a 4.1 fold increased preva-
lence of developing sarcopenia than the “bigger” group, and the
“smaller” group had a 27.5 fold increased prevalence than the “big-
ger” group. These results show that the Yubi-wakka (finger-ring) test
can predict the risk of developing sarcopenia. The results of this study
agree with those of Hiraoka et al.48 and Watanabe et al.49 both show-
ing that the Yubi-wakka (finger-ring) test can predict muscle atrophy
(AUC: 0.654 0.698) and sarcopenia (AUC: 0.66).
Our analysis showed that the OR for sarcopenia was 45.5 fold
higher in women in the “smaller” group and 10.6 fold higher in men
than in the “bigger” group. As stated in the literature, the Yubi-wakka
(finger-ring) test is unlikely to be subject to physique-dependent
biases caused by variations in age and physiology,21 but there may be
gender differences. The sample size and gender ratio of this study
(N = 209, men = 64, women = 145) was quite different from that of
the original study (N = 1904, men = 950, women = 954) by Tanaka et
al.21 which probably affected the odds ratio values for the separate
gender categories. However, odds ratio results for the total cohort
were similar to the original study.
Limitations
All participants in this study were from the same region of Tai-
wan, and a larger, more international and heterogenous sample is
needed for a more robust analysis. In the future, we suggest adding
additional research sites such as long-term care institutions and hos-
pitals to compare the differences. It should also be considered that
most of the participants in this study were females; in the future,
quota sampling should be used to even out the gender ratio. Future
studies should analyze the impact of age, depression, quality of life,
cognitive function, nutrition, and other risk factors on sarcopenia.
Conclusion
The results of this study show that CC has an excellent detection
capacity in both men and women (AUC = 0.877 0.906). This suggests
that CC can be used as a screening tool for sarcopenia; it is simple to
operate and requires only a non-elastic tape measure. The second-
best tool was SARC-Calf, which however may be subject to gender
differences or subjective over- and under-estimation by the partici-
pants due to the nature of self-reporting in questionnaires. The Yubi-
wakka (finger-ring) test, similar in concept to CC, does not require
any tools and can be easily performed with both hands. Our results
show that the “smaller” and “just fits” outcomes are significantly
associated with a diagnosis of sarcopenia.
Funding sources
This research received no external funding.
Conflict of Interest
The authors declare no conflict of interest.
Acknowledgment
The authors would like to thank the research subjects for their
participation.
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