Comparison of Diagnostic Value of the SARC-F and Its Four Modified Versions in Polish Community-Dwelling Older Adults.

Purpose: Sarcopenia is associated with adverse outcomes in elderly persons, including functional disability, falls, and even death. Therefore, older adults should be routinely screened for sarcopenia. Due to the unsatisfactory sensitivity of the SARC-F questionnaire, four modified versions have been elaborated: SARC-CalF, SARC-F+EBM, SARC-F+AC, and SARC-CalF+AC. The diagnostic performance of the four modifications of SARC-F has yet to be compared. Materials and Methods: We performed the sensitivity/specificity analysis and compared the overall diagnostic accuracy of the five questionnaires in 260 community-dwelling volunteers aged ≥ 60 yrs from Poland. The study was performed against three reference standards: the European Working Group on Sarcopenia in Older People (EWGSOP1), EWGSOP2, and modified EWGSOP2 criteria. Results: The prevalence of sarcopenia based on these criteria was 20.8%, 11.2%, and 17.3%, respectively. Concerning the three reference standards, the sensitivity of SARC-F, SARC-CalF, SARC-F+EBM, SARC-F+AC, and SARC-CalF+AC ranged from 31.5-44.8%, 57.4-65.5%, 48.1-62.1%, 71.4-79.2% and 71.4-79.2%, respectively. The specificity ranged from 86.6-87.4%, 86.1-90.3%, 82.3-84.0%, 69.4-78.2%, and 72.1-79.7%, respectively. The AUCs of SARC-F, SARC-CalF, SARC-F+EBM, SARC-F+AC, and SARC-CalF+AC ranged from 0.643-0.700, 0.757-0.792, 0.740-0.775, 0.767-0.812 and 0.771-0.852, respectively. Conclusion: The SARC-F questionnaire has low diagnostic accuracy, which limits its usefulness as a sarcopenia screening tool. Incorporating two simple anthropometric measurements, ie, arm and calf circumference, notably improves the diagnostic performance of SARC-F. Based on our results, SARC-CalF+AC seems to be the best screening tool for sarcopenia screening in community-dwelling older adults.

Applying ACE-III, M-ACE and MMSE to Diagnostic Screening Assessment of Cognitive Functions within the Polish Population.

The research aims to compare the accuracy of the mini-mental state examination (MMSE), the Addenbrooke's cognitive examination III (ACE-III) and the mini-Addenbrooke's cognitive examination (M-ACE) within the Polish population. The model comprised several stages: the features of each test were compared; the shifts in result categorisations between the norm and below the norm were analysed; a third category-mild cognitive impairment (MCI)-was included. Additionally, particular ACE-III domains that scored below domain-specific norm thresholds were analysed to establish the potential early predictors of dementia. All tests correlated to a high and very high degree-cf. MMSE and ACE-III (r = 0.817; p < 0.001), MMSE and M-ACE (r = 0.753; p < 0.001), ACE-III and M-ACE (r = 0.942; p < 0.001). The area under the ROC curve for the ACE-III diagnostic variable had a high value (AUC = 0.920 ± 0.014). A cut-off point of 81 points was suggested for ACE-III; the M-ACE diagnostic variable had an equally high value (AUC = 0.891 ± 0.017). A cut-off point of 20 points was suggested. A significant decrease in the mean score values for people who scored norm or below the norm under ACE-III, as compared to the MMSE results for norm (p < 0.0001), occurred for speech fluency (which decreased by 26.4%). The tests in question are characterised by high sensitivity and specificity. Targeted ACE-III seems best recommended for use in specialised diagnostic centres, whereas M-ACE appears to be a better suited diagnostic alternative for primary health care centres in comparison to MMSE.

Sarcopenia, Obesity, Sarcopenic Obesity and Risk of Poor Nutritional Status in Polish Community-Dwelling Older People Aged 60 Years and Over.

Poor nutritional status (PNS) is a modifiable factor determining abnormalities in body composition-sarcopenia, obesity, and sarcopenic obesity (SO). We aimed to assess the prevalence of these conditions and their association with PNS in 211 community-dwelling older adults. Sarcopenia was diagnosed based on the European Working Group on Sarcopenia in Older People 2 (EWGSOP2) recommendations. Obesity was diagnosed with the Percent Body Fat (>42% in women and >30% in men). Subjects fulfilling the criteria for obesity and concomitantly with reduced lower and/or upper limbs muscle strength and muscle mass (ALM/BMI < 0.512 in women and <0.789 in men) were classified as SO phenotype. Participants without obesity and sarcopenia were categorized as 'normal' phenotype. Nutritional status was estimated with the Mini Nutritional Assessment, and a score of <24 indicated PNS. In total, 49.8% participants had abnormal body composition (60.7% men and 42.5% women; p = 0.001). Sarcopenia, obesity, and SO were diagnosed in 10%, 32.7%, and 7.1% of subjects. PNS was found in 31.3% of the study sample. Its prevalence differed between phenotypes: 81% in sarcopenia, 60% in SO, 14.5% in obesity, and 28.3% in the 'normal' phenotype group (p = 0.000). Based on the results, abnormal body composition is prevalent in elderly subjects. Sarcopenia and SO are often associated with PNS.

Optimal Assessment of Nutritional Status in Older Subjects with the Chronic Obstructive Pulmonary Disease-A Comparison of Three Screening Tools Used in the GLIM Diagnostic Algorithm.

Chronic obstructive pulmonary disease (COPD) is a recognized risk factor for malnutrition. The European Respiratory Society (ERS) statement included nutritional status assessment and dietary intervention as essential components of comprehensive management in subjects with COPD. According to the GLIM algorithm, the first step in diagnosing malnutrition is risk screening with a validated tool. Our study aimed to assess the diagnostic performance of three screening tools (MNA-SF, MUST, and NRS-2002) used in the GLIM algorithm in older patients with COPD. Additionally, we evaluated the agreement between these tools in the diagnostics of malnutrition. We performed a cross-sectional study of 124 patients aged at least 60 years with COPD diagnosed, based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD). We assessed the participants' nutritional status with the three examined screening questionnaires (MNA-SF, MUST, and NRS-2002). Regardless of their results, we performed full malnutrition diagnostics following the GLIM algorithm in all subjects. The proportion of malnourished participants varied from 18.5% for the MUST questionnaire to 27.4% for the MNA-SF and 57.3% for the NRS-2002 score. Based on the GLIM criteria, malnutrition was diagnosed in 48 subjects (38.7%). All assessed questionnaires had an unsatisfactory sensitivity against the GLIM criteria for malnutrition: it was fair (58.3%) for the MNA-SF tool and poor for the MUST and NRS-2002 questionnaires (47.9% for both questionnaires). Considering the negative health consequences of malnutrition, a full diagnostic including GLIM etiologic and phenotypic criteria should be recommended in all elderly patients with COPD, regardless of the screening results.

Socioeconomic Risk Factors of Poor Nutritional Status in Polish Elderly Population: The Results of PolSenior2 Study.

Poor nutritional status (PNS) threatens successful aging. Identifying potentially modifiable predictors of PNS is essential for elaborating a preventive strategy for the population at risk. To assess the prevalence of PNS in the Polish elderly population and analyze its socioeconomic correlates based on the data from the nationwide PolSenior2 project. Special emphasis was put on potentially modifiable factors among the identified PNS predictors. Nutritional status was assessed in 5698 community-dwelling older adults with the Mini Nutritional Assessment-Short Form. We evaluated the effect of age, sex, level of education, marital status, place of residence, subjective loneliness, and self-reported poverty on the nutritional status of the studied subjects. PNS was found in 25.3% of studied subjects (27.7% women and 21.9% men; p < 0.001). Female sex, older age, unmarried status (in men), subjective loneliness, and self-reported poverty were independent correlates of PNS. The two last above-mentioned predictors were identified as potentially modifiable. Based on our results, we recommend preventive interventions (e.g., performing regular screening), particularly in unmarried (men), poorly educated individuals, self-reporting poverty, complaining of loneliness, and the oldest old. PNS preventive strategies should include social support (both emotional and instrumental) to reduce the effect of poverty and subjective loneliness.

Diagnostic Performance and Accuracy of the MNA-SF against GLIM Criteria in Community-Dwelling Older Adults from Poland.

Up to 28% of elderly residents in Europe are at risk of malnutrition. As uniform diagnostic criteria for malnutrition have not been formulated, in autumn 2018, the Global Leadership Initiative on Malnutrition (GLIM) presented a consensus on its diagnosis. According to the consensus, the diagnosis of malnutrition requires a positive screening test result for the risk of malnutrition, and the presence of at least one etiologic and one phenotypic criterion. This study aimed to assess the diagnostic performance and accuracy of the Mini Nutritional Assessment-Short Form (MNA-SF) against GLIM criteria. The analysis involved 273 community-dwelling volunteers aged ≥ 60 years. All participants were screened for malnutrition with the MNA-SF questionnaire. Next, the GLIM phenotypic and etiologic criteria were assessed in all subjects. Based on the presence of at least one phenotypic and one etiologic criterion, malnutrition was diagnosed in more than one-third of participants (n = 103, 37.7%). According to the MNA-SF, only 7.3% of subjects had malnutrition, and 28.2% were at risk of malnutrition. The agreement between the MNA-SF score and the GLIM criteria were observed in only 22.3% of the population. The sensitivity and specificity of MNA-SF against the GLIM criteria were fair (59.2% and 78.8%, respectively). The area under the curve (AUC) was 0.77, indicating the fair ability of MNA-SF to diagnose malnutrition. Based on the present study results, the best solution may be an optional replacement of the screening tool in the first step of the GLIM algorithm with clinical suspicion of malnutrition.

Polish Translation and Validation of the Mini Sarcopenia Risk Assessment (MSRA) Questionnaire to Assess Nutritional and Non-Nutritional Risk Factors of Sarcopenia in Older Adults.

A simple, short, cheap, and reasonably sensitive and specific screening tool assessing both nutritional and non-nutritional risk factors for sarcopenia is needed. Potentially, such a tool may be the Mini Sarcopenia Risk Assessment (MSRA) Questionnaire, which is available in a seven-item (MSRA-7) and five-item (MSRA-5) version. The study's aim was Polish translation and validation of both MSRA versions in 160 volunteers aged ≥60 years. MSRA was validated against the six sets of international diagnostic criteria for sarcopenia used as the reference standards. PL-MSRA-7 and PL-MSRA-5 both had high sensitivity (≥84.9%), regardless of the reference standard. The PL-MSRA-5 had better specificity (44.7-47.2%) than the PL-MSRA-7 (33.1-34.7%). Both questionnaires had similarly low positive predictive value (PL-MSRA-5: 17.9-29.5%; PL-MSRA-7: 14.4-25.2%). The negative predictive value was generally high for both questionnaires (PL-MSRA-7: 89.8-95.9%; PL-MSRA-5: 92.3-98.5%). PL-MSRA-5 had higher accuracy than the PL-MSRA-7 (50.0-55% vs. 39.4-45%, respectively). Based on the results, the Mini Sarcopenia Risk Assessment questionnaire was successfully adopted to the Polish language and validated in community-dwelling older adults from Poland. When compared with PL-MSRA-7, PL-MSRA-5 is a better tool for sarcopenia risk assessment.

Malnutrition, Sarcopenia, and Malnutrition-Sarcopenia Syndrome in Older Adults with COPD.

PURPOSE: Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the world population. In addition to airflow obstruction, COPD is associated with multiple systemic manifestations, including impaired nutritional status or malnutrition and changes in body composition (low muscle mass, LMM). Poor nutritional status and sarcopenia in subjects with COPD leads to a worse prognosis and increases health-related costs. Data from previous studies indicate that 30-60% of subjects with COPD are malnourished, 20-40% have low muscle mass, and 15-21.6% have sarcopenia. This study aimed to assess the prevalence of malnutrition, sarcopenia, and malnutrition-sarcopenia syndrome in elderly subjects with COPD and investigate the relationship between COPD severity and these conditions. PATIENTS AND METHODS: A cross-sectional study involving 124 patients with stable COPD, aged ≥60, participating in a stationary pulmonary rehabilitation program. Nutritional status was assessed following the Global Leadership Initiative on Malnutrition (GLIM) criteria and sarcopenia with the European Working Group on Sarcopenia in Older People 2 (EWGSOP2) criteria. The results of pulmonary function tests and exercise capacity were obtained from the hospital database. RESULTS: 22.6% of participants had malnutrition according to the GLIM criteria. Subjects with malnutrition had lower gait speed (p = 0.0112) and worse results of the Six Minute Walk Test. Sixteen participants (12.9%) had sarcopenia; 12 subjects with sarcopenia had concomitant malnutrition. The prevalence of severe and very severe obstruction (GOLD3/GOLD4) was 91.7%. It was significantly higher in patients with malnutrition-sarcopenia syndrome. CONCLUSIONS: Malnutrition was found in nearly one out of four subjects with COPD, while sarcopenia was one out of seven patients. About 10% of our study sample had malnutrition-sarcopenia syndrome. The prevalence of severe and very severe obstruction was significantly higher in patients with malnutrition-sarcopenia syndrome.

Polish version of SARC-F to assess sarcopenia in older adults: An examination of reliability and validity.

INTRODUCTION: SARC-F is a quick questionnaire recommended as a screening tool for sarcopenia. The aim of the study was to translate, adapt, and validate the Polish version of the SARC-F for community-dwelling older adults in Poland. MATERIALS AND METHODS: We included 160 Polish volunteers aged ≥ 60 years (44% of men). The Polish version of SARC-F was adapted following standardized forward-backward translation procedure. SARC-F was validated against the six sets of diagnostic criteria as the reference standards [developed independently by European Working Group on Sarcopenia in Older People1 (EWGSOP1), European Working Group on Sarcopenia in Older People2 (EWGSOP2), Foundation for the National Institutes of Health (FNIH) Sarcopenia Project, Asia Working Group for Sarcopenia (AWGS), the International Working Group for Sarcopenia (IWGS), and Society on Sarcopenia, Cachexia and Wasting Disorders (SCWD)]. RESULTS: SARC-F score ≥ 4 points was observed in 18.8% of the study population. Cronbach's alpha was 0.70. The sensitivity of SARC-F varied from 33.3% to 50.0% depending on the diagnostics criteria used, while the specificity was about 85%. Positive predictive value (PPV) was low (about 30%) for five out of six sets of the diagnostic criteria used (EWGSOP2, IWGS, AWGS, FNIH, and SCWD), while the negative predictive value (NPV) was generally high (>88%). The area under the ROC curves (AUC) was 0.652-0.728. SARC-F had the largest AUC against FNIH criteria (0.728), indicating a moderate diagnostic accuracy. Similar results were found for EWGSOP2 and IWGS criteria. The AUC values were below 0.7 for AWGS, SCWD, and EWGSOP1 criteria. CONCLUSION: Based on the results, the Polish version of SARC-F shows excellent reliability and good internal consistency. High specificity and high NPV make SARC-F a useful tool to rule-out sarcopenia with high accuracy in community-dwelling older adults, independently of the diagnostic criteria used.

Comparison of Diagnostic Performance of SARC-F and Its Two Modified Versions (SARC-CalF and SARC-F+EBM) in Community-Dwelling Older Adults from Poland.

PURPOSE: Older adults should be routinely screened for sarcopenia, which threatens healthy, independent aging. The most popular screening tool is the SARC-F questionnaire. As its sensitivity is unsatisfactory, two modified versions of the questionnaire have been published: SARC-CalF (including calf circumference as an additional item) and SARC-F+EBM (assessing additionally age and Body Mass Index). The diagnostic performance of the three versions of the questionnaire has not been compared. The analysis aimed to assess the diagnostic value of SARC-F, SARC-CalF, and SARC-F+EBM questionnaires, and to compare their psychometric properties against two reference standards of sarcopenia diagnosis, ie, EWGSOP1 and modified EWGSOP2 criteria. MATERIALS AND METHODS: We performed the sensitivity/specificity analysis and compared the overall diagnostic accuracy of SARC-F, SARC-CalF (31cm) (cut-off point 31 cm for both genders), SARC-CalF (33/34cm) (cut-off points: 33 cm for women and 34 cm for men), and SARC-F+EBM in 115 community-dwelling volunteers aged ≥ 65 yrs from Poland. RESULTS: Depending on the version of the SARC-F questionnaire used, from 10.4% [SARC-CalF (31cm)] to 33.0% (SARC-F+EBM) were identified as having an increased risk of sarcopenia. Sarcopenia was identified in 17.4% by the EWGSOP1 criteria and in 13.9% by the modified EWGSOP2 criteria. With respect to the two reference standards used, the sensitivity of SARC-F, SARC-CalF (31cm), SARC-CalF (33/34cm), and SARC-F+EBM ranged 30.0-37.5%, 35.0-37.5%, 60.0-62.5%, 55.0% (the same value for both reference standards), respectively. The specificity ranged 85.3-85.9%, 93.9-94.7%, 88.4-86.9%, 70.7-71.6%, respectively. The AUC of SARC-F, SARC-CalF (31cm), SARC-CalF (33/34cm) and SARC-F+EBM ranged 0.644-0.693, 0.737-0.783, 0.767-0.804, 0.714-0.715, respectively. CONCLUSION: The modified versions of SARC-F have better diagnostic performance as compared to the original questionnaire. Since an ideal screening tool should have reasonably high sensitivity and specificity, and an AUC value above 0.7, the SARC-CalF (33/34cm) seems to be the best screening tool for sarcopenia in community-dwelling older adults.

Comparison of four sarcopenia screening questionnaires in community-dwelling older adults from Poland using six sets of international diagnostic criteria of sarcopenia.

INTRODUCTION: There are four screening sarcopenia questionnaires (SARC-F, SARC-CalF, MSRA-5, MSRA-7). To unambiguously determine which of them is the most effective tool in community-dwelling older adults, we performed a diagnostic accuracy study. The aim of the analysis was to assess the diagnostic values of SARC-F, SARC-CalF, MSRA-5, MSRA-7 and compare their psychometric properties against six criterion standards (EWGSOP1, EWGSOP2, FNIH, AWGS, IWGS, SCWD criteria). MATERIALS AND METHODS: We included 100 community-dwelling volunteers aged ≥ 65yrs. The sensitivity/specificity analyses were performed. Receiver operating characteristic (ROC) curves and area under the ROC curves (AUC) were calculated to compare the overall diagnostic accuracy of the four questionnaires. Ideal screening tools should have reasonably high sensitivity and specificity, and an AUC value above 0.7. RESULTS: With respect to the six criterion standards used, the sensitivity of SARC-F, SARC-CalF, MSRA-5, and MSRA-7 ranged 35.0-90.0%, 20.0-75.0%, 64.7-90.0%, 76.5-91.7%, respectively, whereas the specificity ranged 86.9-91.1%, 80.0-90.0%, 45.8-48.8%, 28.9-31.0% respectively. The AUCs of SARC-F, SARC-CalF, MSRA-5, and MSRA-7 ranged from 0.655-0.882, 0.711-0.874, 0.618-0.782 and 0.588-0.711 respectively. Only SARC-CalF had AUC >0.7 and <0.9 against the six criterion standards but obesity was a confounding factor, which may affect the diagnostic power of SARC-CalF. MSRA-7 had the smallest AUC of all the questionnaires and MSRA-5 had slightly larger AUC than MSRA-7. CONCLUSION: Based on our analysis, the standard sarcopenia screening questionnaires deliver contradictory results in many practically occurring cases. It appears that SARC-CalF is an optimal choice for screening sarcopenia in community-dwelling older adults.

Analgesic use among nursing homes residents, with and without dementia, in Poland.

Many age-associated diseases are accompanied by pain. There is no doubt that pain is underrecognized among elderly nursing home residents and the diagnosing of pain is a real challenge in subjects with dementia. The aim of the study was to characterize analgesic use among nursing home residents and to delineate the putative associations between pain management and cognitive functions of elderly persons. The study involved 392 subjects (males:females - 81:311) with a mean age of 83.6±5.9 years. The residents' medical files in relation to diagnoses and drug consumption were analyzed, and the screening of cognitive functions was performed using the Mini-Mental State Examination (MMSE). One hundred and thirteen residents (28.8%) received some analgesics. Among them 84 (21.4%) used them routinely, 25 (6.4%) - pro re nata (PRN) and four (1.0%) - both routinely and PRN. Non-opioid analgesics were taken routinely by 53 residents, weak opioids by nine subjects, and one person was receiving strong opioids. Additionally, three individuals were taking a combination preparation of tramadol and acetaminophen. The rate of subjects who were not receiving any pain treatment was higher in residents with MMSE between 0 and 9 points than in those with MMSE between 24 and 30 points (P=0.0151). Furthermore, ten residents (9.1%) with severe dementia were treated with analgesics PRN. The results of our study point to a remarkably low use of analgesics in nursing home residents in Poland and indicate a need to introduce pain evaluation and monitoring of drug treatment appropriateness as a standard procedure in the geriatric assessment in nursing homes.

Effects of inpatient physical therapy on the functional status of elderly individuals.

Purpose] The aim of the study was to analyze the impact of inpatient rehabilitation on the functional status of the elderly. [Subjects and Methods] A total of 100 patients (>65 years of age) in a rehabilitation ward were enrolled in this study. Age, absence of depression and signs of dementia in screening tests constituted the inclusion criteria. A comprehensive geriatric assessment was performed of all of the subjects twice, at the beginning and end of hospitalization (Assessments I and II, respectively), and included fall risk assessment (Timed Up and Go Test, TUG), evaluation of physical function (Short Physical Performance Battery Test, SPPB), the handgrip strength test, as well as patients' self-reports of pain intensity, well-being and functional status. [Results] At the end of inpatient rehabilitation, significant improvement was observed in reduction the TUG time, physical function, and handgrip strength, as well as in subjective parameters such as self-reported pain intensity, well-being, and functional status. [Conclusion] Our results show the high efficacy of inpatient rehabilitation as a means of improving functional independence. Hospital rehabilitation should be recommended for elderly people, not only in cases of absolute indications for hospital admission, but also periodically for patients at risk of physical disability.

The Effect of a 12-Week Omega-3 Supplementation on Body Composition, Muscle Strength and Physical Performance in Elderly Individuals with Decreased Muscle Mass.

The aim of the study was to assess the effect of a polyunsaturated omega-3 fatty acids (PUFA) supplementation on the parameters of body composition, muscle strength and physical performance in elderly people with decreased muscle mass (DMM). Fifty three elderly people with an ALM index (the ratio of appendicular lean mass to squared height) either below (-2SD: low muscle mass-LMM) or between (-1SD and -2SD: the risk of LMM-rLMM) the ALM index for the young Polish reference population were randomly assigned to PUFA-treated groups (LMM-PUFA, rLMM-PUFA) or control groups (LMM-control, rLMM-control). PUFA-treated groups received capsules containing 1.3 g of PUFA and 10 mg of vitamin E, while the control groups received 11 mg of vitamin E daily for 12 weeks. Body composition (BIA analysis), muscle strength (hand grip measured with dynamometer) and physical performance (Timed Up and Go test-TUG) were assessed before and after supplementation. No statistically significant differences were observed either in muscle mass or in the hand grip and TUG in any group. The post-pre difference (mean ± SD) in ALM index was as follows (kg/m²): LMM-PUFA: 0.00 ± 0.30, rLMM-PUFA: 0.00 ± 0.22, LMM-control: 0.03 ± 0.36, rLMM-control: -0.03 ± 0.20. In our study, a 12 week supplementation of PUFA did not affect the evaluated parameters in elderly individuals with DMM.

The significance of body mass index in calculating the cut-off points for low muscle mass in the elderly: methodological issues.

OBJECTIVES: Cut-off points (COPs) for appendicular lean mass (ALM) index, essential to define low muscle mass (LMM) in the elderly, have never been officially defined for Poland. The aim of the study was to establish them. Additionally, the significance of body mass index (BMI) for correctly defining the COPs in a young, healthy reference group was assessed. METHODS: The study was composed of reference group (n = 1113) and the elderly group (n = 200). In all subjects, body composition was assessed by bioimpedance analysis, and ALM index was calculated. Next, COPs (kg/m(2)) were set up for the whole reference group and for particular subgroups with different BMIs separately. They were used to diagnose sarcopenia in the elderly. RESULTS: COP for all young females was 5.37 (COP-F), while it was equal to 5.52 (COP-F2) when only those with a recommended BMI (18.50-24.99 kg/m(2)) were taken into consideration. For males, it was 7.32 and 7.29, respectively. Only 7% of elderly females had LMM based on COP-F and 15% had LMM based on COP-F2 (P < 0.05); for males, the percentages were 18% and 16%, respectively. CONCLUSIONS: COPs for LMM for Poland are 5.52 kg/m(2) (females) and 7.29 kg/m(2) (males). The reference group BMI is an important factor in establishing COPs for low muscle mass.