Figures
Abstract
Sarcopenia is a progressive generalized skeletal muscle disorder, which may increase the risk of osteopenia. The aim of this study was to systematically review studies on the association between sarcopenia and osteopenia by pooled analysis. The PubMed and Embase databases were searched from inception to October 2020 for studies focusing on the association between sarcopenia and osteopenia. Two reviewers independently extracted data and assessed study quality. A pooled analysis was performed to calculate odds ratios (ORs) and 95% confidence intervals (CIs) using random-effects models. Subgroup analysis was conducted to explore the source of heterogeneity and the stability of outcome. A total of 25 independent studies involving 47,744 participants fulfilled the inclusion criteria. Sarcopenia significantly increased the risk of osteopenia (OR, 2.08; 95% CI, 1.66–2.60); Sensitivity analyses indicated the outcome was stable. Subgroup analyses showed that sarcopenia significantly increased osteopenia risk in each subgroup. No evidence of publication bias among the studies existed. In this study, our findings showed that sarcopenia significantly increased the risk of osteopenia. Thus, we suggest that sarcopenia can be a predictor of osteopenia risk.
Citation: Teng Z, Zhu Y, Yu X, Liu J, Long Q, Zeng Y, et al. (2021) An analysis and systematic review of sarcopenia increasing osteopenia risk. PLoS ONE 16(4): e0250437. https://doi.org/10.1371/journal.pone.0250437
Editor: Alessandra Coin, Clinca Geriatrica, ITALY
Received: December 24, 2020; Accepted: April 7, 2021; Published: April 28, 2021
Copyright: © 2021 Teng et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript, its Supporting information files, and on Figshare (DOI: 10.6084/m9.figshare.14080040.v1).
Funding: This project was funded by the National Natural Science Foundation of China under grant nos. 31960136 (Zhaowei Teng), 81760136 (Yun Zhu), 81660156 (Zhaowei Teng), 81960268 (Sheng Lu); by the Joint Special Fund of Applied Fundamental Research of Kunming Medical University granted by the Science and Technology Office of Yunnan under grant nos. 2018FE001(-175) (Zhaowei Teng) and 2018FE001(-174) (Yun Zhu); and by the Yunnan Health Training Project of High-level Talents under grant nos. H-2017064 (Zhaowei Teng) and H-2017028 (Yun Zhu). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Sarcopenia is a muscle disorder involving depletion of skeletal muscle mass with a risk of adverse outcomes, such as physical disability and poor quality of life [1], is associated with many clinical conditions, such as cancer, diabetes, rheumatoid arthritis, and osteopenia [2–4]. Osteopenia, defined by the World Health Organization that is a t-score between -1 to -2.5, is a clinical term used to describe a decrease in bone mineral density [5]. Projections estimate that over 47 million Americans will be afflicted with osteopenia [5, 6]. Thus osteopenia is one of the major public health problems globally, and the burden is extremely heavy.
Some studies have indicated that osteopenia is associated with an increased risk of sarcopenia [4, 7–16]. However, others have shown no significant association exists between sarcopenia and osteopenia [17–19]. Therefore, we performed a pooled analysis to assess the relationship between sarcopenia and osteopenia risk.
Methods
This analysis was conducted in accordance with the Meta-analysis of Observational Studies in Epidemiology guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-analyses standards [20, 21].
Search strategy and selection of eligible studies
We systematically searched PubMed and Embase (from their inception to October 1, 2020) for studies conducted on the association between sarcopenia and osteopenia. Our core search keywords are as follows: “sarcopenia”, “osteopenia”, and “low bone mineral density”. Two researchers (TZW and ZY) independently reviewed the titles and abstracts of the studies retrieved from the databases. We included studies that reported sufficient data on sarcopenia increasing osteopenia risk, such as risk estimates (relative risks [RRs], odds ratios [ORs]) with 95% confidence intervals (CIs). The studies were assessed based on the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement [20]. All disagreements were resolved by discussion with the corresponding authors.
Data extraction and analysis
The data extraction and analysis were similar as our previous studies [22]. The following variables were recorded as: name of the first author, year of publication, region in which the study was performed, type of study design, sample size, participant gender and age, risk estimates with 95% CIs, adjustment factors. When one study included more than one trial, we pooled the trials and considered each trial an independent study. We computed a pooled OR and 95% CI. The Cochrane Q and I2 statistics were used to evaluate the statistical heterogeneity [23]. When the P value was < 0.1 and the I2 value was > 50%, the data were considered to be heterogeneous, and a random-effects model [24] was applied. To further explore the origin of heterogeneity and the stability of conclusion, we also performed subgroup analyses by sex, study design, study region, and criteria of sarcopenia. A sensitivity analysis was conducted to estimate the influence of each individual study on the pooled result. Begg’s test and Egger’s test were used to assess the potential publication bias [25, 26]. STATA version 12.0 (College Station, TX, USA) was used to analyze the data.
Results
Selected studies
A total of 1727 studies were retrieved from PubMed and Embase, after removing duplicates, 1475 were identified. After screening the title and abstract, 288 necessitated reading of the full article. Ultimately, 20 studies [4, 7–19, 27–32] involving 47,744 participants were included (Fig 1). The study characteristics are listed in Table 1. The quality of the studies access by the STROBE statement (S1 Table).
Main analysis
A pooled analysis of 20 studies involving 25 researches showed that sarcopenia significantly increased osteopenia risk (OR, 2.08 [95% CI, 1.66–2.60]; Pheterogeneity = 0.000, I2 = 86.1%) (Fig 2). Substantial heterogeneity was observed (P<0.10, I2 >50%) (Fig 2); however, the analysis revealed that exclusion of any single study did not alter the overall combined results, which indicated that the outcome was stable (Fig 3). Subgroup pooled analyses performed according to gender, study design type, different criteria of sarcopenia, and region also indicated that sarcopenia significantly increased osteopenia risk in each subgroup (Table 2). The Begg and Egger test indicated no evidence of publication bias among the studies [Begg, P > |z| = 0.168; Egger, P = 0.058, 95% CI -0.055–3.098] (Fig 4).
The analysis was performed via recalculation of the pooled results of the primary analysis after exclusion of one study per iteration.
A, Begg’s funnel plot. B, Egger’s publication bias plot.
Discussion
Osteopenia is characterized by loss of bone mass, reduced bone mineral density, which will develop into osteoporosis, may further lead to heavy economic and social burdens. Sarcopenia is one of the most important contributing factors related to osteopenia. Muscle and bone are interconnected biochemically and biomechanically, and they can mutually influence each other [33, 34]. Sarcopaenia and osteopaenia are two musculoskeletal pathologies mutually influencing each other, both associated with aging, lifestyle factors, falls and fractures [1, 3]. Thus, sarcopenia and osteopaenia frequently occur concomitantly, which leads to osteosarcopenia, and all of these conditions are critically associated with bone fragility, increased fall risk, fractures [35]. And osteosarcopaenia should be consciously incorporated into daily life and therapeutic strategies. This pooled analysis indicated that sarcopenia significantly increased osteopenia risk. Although heterogeneity was substantial, sensitivity analysis did not alter the overall combined results, subgroup analyses showed that sarcopenia significantly increased the risk of osteopenia in each pooled subgroup, which all demonstrated the credibility of the results. This pooled analysis has strengthened previous findings, for example, one study showed that older women with sarcopenia exhibited lower bone mineral density than those without sarcopenia [35]. Therefore, it may be possible to prevent osteopenia and related adverse events by the treatment of sarcopenia.
This study has several limitations. First, the study design included cross-sectional studies, case-control studies, and others, which might have led to substantial heterogeneity. Second, some trials did not provide the data as estimates with 95% CIs, so we had to calculate these values according to specific numbers of participants, which might have influenced the accuracy of the results. Third, different studies used different diagnostic criteria for sarcopenia, which might have slightly affected the results. Therefore, the results should be interpreted with caution.
Conclusion
In this study, our findings showed that sarcopenia significantly increases osteopenia risk. However, care should be taken when interpreting the findings, and large randomized controlled trials are still needed to further specify the association between osteopenia and sarcopenia.
Supporting information
S1 Table. Methodological quality of studies included in the final analysis based on STROBE statement checklists.
https://doi.org/10.1371/journal.pone.0250437.s001
(PDF)
Acknowledgments
We appreciate the contribution of all patients, their families, the investigator and the medical staff.
References
- 1. Cruz-Jentoft AJ, Sayer AA. Sarcopenia. Lancet. 2019;393(10191):2636–46. Epub 2019/06/07. pmid:31171417.
- 2. Kanis JA, Cooper C, Rizzoli R, Reginster JY, Scientific Advisory Board of the European Society for Clinical and Economic Aspects of Osteoporosis (ESCEO), The Committees of Scientific Advisors and National Societies of the International Osteoporosis Foundation (IOF). European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int. 2019;30(1):3–44. pmid:30324412.
- 3. Compston JE, McClung MR, Leslie WD. Osteoporosis. Lancet (London, England). 2019;393(10169):364–76. Epub 2019/01/31. pmid:30696576.
- 4. Bieliuniene E, Brondum Frokjaer J, Pockevicius A, Kemesiene J, Lukosevicius S, Basevicius A, et al. CT- and MRI-Based Assessment of Body Composition and Pancreatic Fibrosis Reveals High Incidence of Clinically Significant Metabolic Changes That Affect the Quality of Life and Treatment Outcomes of Patients with Chronic Pancreatitis and Pancreatic Cancer. Medicina (Kaunas, Lithuania). 2019;55(10). Epub 2019/10/02. pmid:31569661.
- 5.
Varacallo M, Seaman TJ, Jandu JS, Pizzutillo P. Osteopenia. StatPearls. Treasure Island (FL): StatPearls Publishing Copyright © 2020, StatPearls Publishing LLC.; 2020.
- 6. Varacallo MA, Fox EJ, Paul EM, Hassenbein SE, Warlow PM. Patients’ response toward an automated orthopedic osteoporosis intervention program. Geriatric orthopaedic surgery & rehabilitation. 2013;4(3):89–98. Epub 2013/12/10. pmid:24319621.
- 7. Santos VRD, Christofaro DGD, Gomes IC, Junior IFF, Gobbo LA. Relationship between obesity, sarcopenia, sarcopenic obesity, and bone mineral density in elderly subjects aged 80 years and over. Revista brasileira de ortopedia. 2018;53(3):300–5. Epub 2018/06/13. pmid:29892580.
- 8. Schneider S, Al-Jaouni R, Filippi J, Wiroth JB, Zeanandin G, Arab K, et al. Sarcopenia is prevalent in patients with Crohn’s disease in clinical remission. Inflammatory bowel diseases. 2008;14(11):1562–8. pmid:18478564
- 9. Falutz J, Rosenthall L, Guaraldi G. Association of osteoporosis and sarcopenia in treated HIV patients. Antiviral Therapy. 2013;18:A17.
- 10. Lee SG, Lee YH, Kim KJ, Lee W, Kwon OH, Kim JH. Additive association of vitamin D insufficiency and sarcopenia with low femoral bone mineral density in noninstitutionalized elderly population: the Korea National Health and Nutrition Examination Surveys 2009–2010. Osteoporosis international: a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA. 2013;24(11):2789–99. Epub 2013/05/09. pmid:23652463.
- 11. Wu CH, Yang KC, Chang HH, Yen JF, Tsai KS, Huang KC. Sarcopenia is related to increased risk for low bone mineral density. Journal of clinical densitometry: the official journal of the International Society for Clinical Densitometry. 2013;16(1):98–103. Epub 2012/09/15. pmid:22975297.
- 12. Bryant RV, Ooi S, Schultz CG, Goess C, Grafton R, Hughes J, et al. Low muscle mass and sarcopenia: common and predictive of osteopenia in inflammatory bowel disease. Alimentary pharmacology & therapeutics. 2015;41(9):895–906. Epub 2015/03/11. pmid:25753216.
- 13. Pereira FB, Leite AF, de Paula AP. Relationship between pre-sarcopenia, sarcopenia and bone mineral density in elderly men. Archives of endocrinology and metabolism. 2015;59(1):59–65. Epub 2015/05/01. pmid:25926116.
- 14. Chung SM, Hyun MH, Lee E, Seo HS. Novel effects of sarcopenic osteoarthritis on metabolic syndrome, insulin resistance, osteoporosis, and bone fracture: the national survey. Osteoporosis international: a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA. 2016;27(8):2447–57. Epub 2016/05/15. pmid:27177746.
- 15. He H, Liu Y, Tian Q, Papasian CJ, Hu T, Deng HW. Relationship of sarcopenia and body composition with osteoporosis. Osteoporosis international: a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA. 2016;27(2):473–82. Epub 2015/08/06. pmid:26243357.
- 16. Lee DW, Choi EY. Sarcopenia as an Independent Risk Factor for Decreased BMD in COPD Patients: Korean National Health and Nutrition Examination Surveys IV and V (2008–2011). PloS one. 2016;11(10):e0164303. Epub 2016/10/18. pmid:27749901.
- 17. Lee I, Cho J, Jin Y, Ha C, Kim T, Kang H. Body Fat and Physical Activity Modulate the Association Between Sarcopenia and Osteoporosis in Elderly Korean Women. Journal of sports science & medicine. 2016;15(3):477–82. Epub 2016/11/03. pmid:27803626.
- 18. Lee I, Ha C, Kang H. Association of sarcopenia and physical activity with femur bone mineral density in elderly women. Journal of exercise nutrition & biochemistry. 2016;20(1):23–8. Epub 2016/06/15. pmid:27298809.
- 19. Kim IJ, Kang KY. Low Skeletal Muscle Mass is Associated with the Risk of Low Bone Mineral Density in Urban Dwelling Pr emenopausal Women. Calcified tissue international. 2017;101(6):581–92. pmid:28828511.
- 20. Vandenbroucke JP, von Elm E, Altman DG, Gotzsche PC, Mulrow CD, Pocock SJ, et al. Strengthening the reporting of observational studies in epidemiology (STROBE): explanation and elaboration. PLoS Med. 2007;4(10):e297. pmid:17941715.
- 21. Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. Jama. 2000;283(15):2008–12. pmid:10789670.
- 22. Teng Z, Zhu Y, Wu F, Zhu Y, Zhang X, Zhang C, et al. Opioids contribute to fracture risk: a meta-analysis of 8 cohort studies. PloS one. 2015;10(6):e0128232. Epub 2015/06/02. pmid:26030421.
- 23. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414):557–60. pmid:12958120.
- 24. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7(3):177–88. pmid:3802833.
- 25. Begg CB, Mazumdar M. Operating characteristics of a rank correlation test for publication bias. Biometrics. 1994;50(4):1088–101. pmid:7786990.
- 26. Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. Bmj. 1997;315(7109):629–34. Epub 1997/10/06. pmid:9310563.
- 27. Choi CJ, Choi WS, Kim CM, Lee SY, Kim KS. Risk of Sarcopenia and Osteoporosis in Male Tuberculosis Survivors: Korea National Health and Nutrition Examination Survey. Scientific reports. 2017;7(1):13127. Epub 2017/10/17. pmid:29030560.
- 28. França NAG, Peters BSE, Lima MMS, Santos EA, Santos PC, Martini LA. Muscle mass as the main component of body composition associated with bone mineral density. Osteoporosis International. 2017;28:S210–S1.
- 29. Harris R, Chang Y, Beavers K, Laddu-Patel D, Bea J, Johnson K, et al. Risk of Fracture in Women with Sarcopenia, Low Bone Mass, or Both. Journal of the American Geriatrics Society. 2017;65(12):2673–8. Epub 2017/09/30. pmid:28960230.
- 30. Hwang JA, Kim YS, Leem AY, Park MS, Kim SK, Chang J, et al. Clinical Implications of Sarcopenia on Decreased Bone Density in Men With COPD. Chest. 2017;151(5):1018–27. Epub 2016/12/26. pmid:28012805.
- 31. Krajewska-Wlodarczyk M, Owczarczyk-Saczonek A, Placek W. Changes in body composition and bone mineral density in postmenopausal women with psoriatic arthritis. Reumatologia. 2017;55(5):215–21. pmid:29332959
- 32. Lee DW, Jin HJ, Shin KC, Chung JH, Lee HW, Lee KH. Presence of sarcopenia in asthma-COPD overlap syndrome may be a risk factor for decreased bone-mineral density, unlike asthma: Korean National Health and Nutrition Examination Survey (KNHANES) IV and V (2008–2011). International journal of chronic obstructive pulmonary disease. 2017;12:2355–62. Epub 2017/08/30. pmid:28848336.
- 33. Di Monaco M, Castiglioni C, Bardesono F, Milano E, Massazza G. Sarcopenia, osteoporosis and the burden of prevalent vertebral fractures: a cross-sectional study of 350 women with hip fracture. European journal of physical and rehabilitation medicine [Internet]. February 12, 2020 Feb 12. https://www.ncbi.nlm.nih.gov/pubmed/32052946. pmid:32052946
- 34. Maurel DB, Jahn K, Lara-Castillo N. Muscle-bone crosstalk: emerging opportunities for novel therapeutic approaches to treat musculoskeletal pathologies. Biomedicines. 2017;5(4):E62. pmid:29064421.
- 35. Lima RM, de Oliveira RJ, Raposo R, Neri SGR, Gadelha AB. Stages of sarcopenia, bone mineral density, and the prevalence of osteoporosis in older women. Archives of osteoporosis. 2019;14(1):38. Epub 2019/03/15. pmid:30868338.