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Mediterranean Journal of Nutritionand MetabolismOfficial Journal of the Italian Associationfor Dietetics and Clinical Nutrition (ADI)a member of the Italian Federation ofNutritional Societies (FeSIN) ISSN 1973-798X Mediterr J Nutr MetabDOI 10.1007/s12349-013-0135-1

Body composition in sarcopenic obesity:systematic review of the literature

Lorenzo M. Donini, EleonoraPoggiogalle, Silvia Migliaccio, AntonioAversa & Alessandro Pinto

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REVIEW

Body composition in sarcopenic obesity: systematic reviewof the literature

Lorenzo M. Donini • Eleonora Poggiogalle •

Silvia Migliaccio • Antonio Aversa •

Alessandro Pinto

Received: 23 August 2013 / Accepted: 27 August 2013

� Springer-Verlag Italia 2013

Abstract Although, recently a mounting interest in the

literature has been directed to sarcopenic obesity, currently,

different definitions of sarcopenic obesity (SO) exist and

diagnostic criteria are not universally established. The aim

of the present systematic review is to summarize the state

of the art according to extant literature about this topic. A

systematic review of the literature was performed consid-

ering the revision question: ‘‘sarcopenic obesity: body

composition’’. Analysis and presentation of the outcomes

were carried out in the form of a narrative resume of the

reports. Twenty-six studies were considered eligible for the

systematic review involving globally more than 23,000

subjects. In all the studies examined, except one, the def-

inition of sarcopenic obesity was based on the co-presence

of obesity and sarcopenia. With respect to obesity, different

parameters (body mass index, fat mass and visceral fat

area) were used (as single parameters or in association to

the other adiposity measures). For sarcopenia, the appen-

dicular skeletal muscle mass standardized for height or

weight, cross-sectional area at the quadriceps level, muscle

strength and/or muscle/fat-free mass indexes were consid-

ered. Body composition analysis was performed, depend-

ing on the studies, through DXA scan, CT scan

bioimpedance analysis, dynamometer test or anthropo-

metric parameters. To date, just few papers provided clear

and shared diagnostic criteria of SO. In fact, in our review,

criteria adopted by single authors were only partially

overlapping. One of the main obstacles is represented by

the definition of SO, and especially whether it should be

based only on criteria of body composition or also func-

tional criteria should be taken into account.

Keywords Obesity � Sarcopenia �Sarcopenic obesity

Introduction

Recently, a mounting interest in the literature has been

directed to sarcopenic obesity (SO), a clinical and func-

tional condition characterized by the coexistence of excess

fat mass (FM) and reduced fat-free mass (FFM), showing

the cumulative risk derived from each of the two individual

body composition phenotypes [1–4]. Especially, sarcopenic

obesity tends to be more common in elderly subjects or in

younger obese subjects with severe disability, as well as it

may occur in obese subjects after bariatric surgery without

nutritional supervision or in response to long-lasting

incongruous dietary regimens [5–9].

Conflicting data exist about the link between sarcopenia

and functional impairment [11, 12]. However, as an asso-

ciation between obesity per se and poor physical perfor-

mance has been demonstrated, long-term consequences of

sarcopenia on physical performance are potentially more

severe in obese elder individuals [10, 13, 14]. In obese

adults, an imbalance between lean mass and excess body

fat and total body size appears earlier than the onset of old

age [5, 6]. This precocious phenomenon is due to the dis-

proportion between lean mass, even when preserved, when

compared to fat mass, exceeding the weight that lean mass

could support. The pathogenetic and functional role of

L. M. Donini (&) � E. Poggiogalle � A. Aversa � A. Pinto

Food Science and Endocrinology Section, Department of

Experimental Medicine, Medical Physiopathology, Sapienza

University of Rome, P.le Aldo Moro, 5, 00185 Rome, Italy

e-mail: lorenzomaria.donini@uniroma1.it

S. Migliaccio

Unit of Endocrinology, Department of Movement, Human and

Health Sciences, University of Rome ‘‘Foro Italico’’, Rome, Italy

123

Mediterr J Nutr Metab

DOI 10.1007/s12349-013-0135-1

Author's personal copy

sarcopenia or ‘‘relative’’ sarcopenia in obese elderly sub-

jects as well as in younger adults remains to be better

clarified.

Currently, different definitions of sarcopenic obesity

exist and diagnostic criteria are not universally established.

Hence, prevalence of sarcopenic obesity ranges from 2.75

to over 20 %, depending on the criteria used for the diag-

nosis and methods for body composition assessment [6,

15].

As sarcopenic obese subjects require more specific

nutritional rehabilitation protocols, specific nutritional and

body composition parameters need to be better identified

and evaluated.

The aim of the present systematic review is to summa-

rize the state of the art according to extant literature about

this topic.

Materials and methods

The present systematic review was performed following

the steps by Egger et al. [16], as follows:

1. configuration of a working group at the ‘‘Sapienza’’

University of Rome: three operators skilled in clinical

nutrition in the geriatric age, of whom one acting as a

methodological operator (LMD) and two participating

as clinical operators (EP, AP);

2. formulation of the revision question on the basis of the

considerations made in the introduction: ‘‘sarcopenic

obesity: body composition’’;

3. identification of relevant studies: a research strategy

was planned, on PubMed [Public Medline run by the

National Center of Biotechnology Information (NCBI)

of the National Library of Medicine of Bethesda

(USA)], as follows:

a. definition of the key words (sarcopenic obesity,

body composition, fat-free mass, fat mass), allow-

ing the definition of the interest field of the

documents to be searched, grouped in inverted

commas (‘‘…’’) and used separately or in

combination;

b. use of: the boolean AND operator, that allows the

establishment of logical relations among concepts;

c. research modalities: advanced search;

d. limits:

i. time limits: papers published in the last

20 years;

ii. humans;

iii. languages: English, French, Italian;

e. Manual search performed by the senior researchers

(LMD and AP) experienced in clinical nutrition

through the revision of reviews and individual

articles on nutrition and body composition pub-

lished in journals qualified in the Index Medicus:

4. analysis and presentation of the outcomes: the data

extrapolated from the revised studies were collected in

tables; in particular, for each study we specified: the

author, the name of the journal where the study was

published and year of publication, study characteristics

(design, setting, selection criteria, subjects included,

duration of the study, measure of mortality, …);

5. the analysis was carried out in the form of a narrative

resume of the reports

Results

Twenty-six studies were considered eligible for the sys-

tematic review [1, 5, 10, 17–39]. Tables 1 and 2 summarize

the description of study samples, procedures used to

diagnose sarcopenic obesity and the threshold values used

for sarcopenic obesity definition.

Globally, more than 23,000 subjects were studied. In

seven papers [5, 20, 29, 32, 33, 35, 37] participants were

Caucasian; one study [21] involved also African-American

subjects whereas in eight studies Asian subjects were

included [18, 22–25, 27, 30, 34]; in two papers there were

also Hispanic participants [1, 10], and one study involved

Maori individuals and Pacific Islanders [39].

In all the studies examined, except one, the definition of

sarcopenic obesity was based on the co-presence of obesity

and sarcopenia. Only in one study another definition was

chosen [18], using the calculation of the adiposity to

muscle ratio (body adiposity bearing on a unit of muscle

mass): a value above or below 0.75 was predictive of

incident or worsening physical limitation [18].

Excluding the latter study [18] in all the papers obesity

and sarcopenia were defined separately.

With respect to obesity, the following parameters were

used (as single parameters or in association to the other

adiposity measures):

– body mass index (BMI) [30 kg/m2 in nine studies [5,

22, 28, 29, 31, 33, 35–37];

– waist circumference in four studies [5, 26, 33, 35]

[102 cm in men and 88 cm in women or values higher

than the upper sex-specific tertile or quartile;

– fat mass (FM) expressed as body weight percentage in

eleven studies (10, 18, 20–23, 34, 37, 39 e 42), with

threshold values ranging from 27 to 30 % in men and

from 35 and 40 % in women (while in two studies a

unique cut-off value was applied for both the genders).

Fat mass index (FMI) was used in two studies [35, 38]

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Table 1 Methods for body composition evaluation

References Sample Sarcopenia Obesity

Aubertin-Leheudre

et al. [17]

60 postmenopausal healthy women ages 55–75 years DXA DXA

Auyeung et al. [18] 4000 community-dwelling men and women aged 65 years or over

were recruited in a project primarily examining the bone mineral

density of older Chinese adults. Only ethnical Chinese subjects

DXA DXA

Barbat-Artigas et al.

[19]

112 Postmenopausal women aged 50–77 years DXA DXA

Baumgartner [1] 831 subjects (Hispanic and nonHispanic 60 years and older) from

New Mexico Elder Health Survey and the New Mexico Aging

Process Study

DXA DXA

Baumgartner et al.

[10]

451 healthy elderly from the New Mexico Aging Process Study (with

no disability at baseline)

DXA DXA

Caucasian (90 %) and Hispanic and nonwhite (other) 60 years and

older

Bouchard et al. [20] 894 subjects from the Nutrition as a determinant of successful aging

(French-Canadians); age: 68–82 years

DXA DXA

Cesari et al. [21] 286 subjects with high cardiovascular risk profile participating to the

TRAIN study: Caucasian (75 %) African-American (23 %) and

other

DXA DXA

Chung et al. [22] 4471 subjects (1856 men, 2615 women) older than 60 years of age

from the KNHANES (cross-sectional and nationally representative

survey conducted by the Korean Ministry of Health and Welfare)

DXA Anthropometrics (BMI)

Kim et al. [23] 493 subjects (180 men and 313 women) from the Korean Sarcopenic

Obesity Study (KSOS) within three age groups; 20–39 (n = 127;

young reference group), 40–59 (n = 178), and C60 years

(n = 188).

DXA and CT DXA and CT

Kohara et al. [24] 782 independent middle-aged to elderly persons recruited from

visitors to the Anti-Aging Center at Ehime University Hospital

(Japan) from March 2006 to March 2009

CT CT

Lu et al. [25] 600 community-dwelling individuals in Northern Taiwan aged

63.6 ± 10.1 years

BIA BIA

Levine and

Crimmins [26]

Males and females aged 60 and older from the National Health and

Nutrition Examination Survey (NHANES 1999–2004)

DXA Anthropometrics (WC)

Lim et al. [27] 565 subjects from the Korean Longitudinal Study on Health and

Aging 65 and older

DXA CT

Messier et al. [28] 136 postmenopausal women participating in the Montreal Ottawa

New Emerging Team study (Canada) 46–70 years of age

DXA Anthropometrics (BMI)

Monteiro et al. [29] 239 postmenopausal healthy Caucasian women (age:

57.4 ± 6.6 years)

BIA Anthropometrics (BMI)

Ochi et al. [30] 410 Japanese middle-aged to elderly subjects CT CT

Prado et al. [31] 250 patients with cancers of the lung or gastrointestinal tracts treated

in Canada. Age range: 35–88 years

CT Anthropometrics (BMI)

Rolland et al. [32] 1308 elderly French women from EPIDemiologie de l’OSteoporose

Study [75 years

DXA DXA

Schrager et al. [33] 871 participants from the InChianti study (Tuscany, Italy) [65 years Handgrip strength Anthropometrics (BMI,

WC)

Seo et al. [34] 484 subjects from the Korean Ansan Geriatric Study aged [65 years DXA DXA and CT

Siervo et al. [35] 763 overweight and obese women; age range 18–87 years from

Naples (Italy)

BIA Anthropometrics (BMI,

WC) and BIA

Srikanthan et al.

[36]

2370 women and 2284 men participating to the National Health and

Nutrition Examination Survey

BIA Anthropometrics (BMI)

(NHANES) III [60 years

Stenholm et al. [5] 2099 subjects from Health 200 Survey Finnish population; 55 and

older

Handgrip strength Anthropometrics (BMI,

WC) and BIA

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involving only female participants: threshold values

were 9.5 and 11.8 kg/m2, respectively;

– visceral fat area was measured in six studies [23–25,

27, 30, 34], all using a cut-off value of 100 cm2 in both

men and women.

For sarcopenia the following parameters were used:

– appendicular skeletal muscle mass standardized for

height (ASM/ht2) in ten studies [1, 10, 19, 20, 28, 29,

32, 34, 35, 39] or body weight (ASM/Wt) in five

studies [22, 23, 26, 27, 36]. Threshold values were

established as 1 or 2 standard deviation(SD)(s) below

values for sex-specific mean for healthy young adults;

– cross-sectional area at the quadriceps level (in relation

to body weight in three studies and to height in one

paper) [24, 25, 30, 31]. Also in this case, threshold

values were considered as 1 SD below values for sex-

specific mean for healthy young adults;

– muscle strength (handgrip strength o knee extension)

[5, 33, 37, 38] considering as cut-off value the lower

sex-specific tertile or quartile;

– muscle mass index (MMI) or fat-free mass index

(FFMI) in two studies [17, 38] compared to values in a

reference population.

Body composition analysis was performed, especially

with respect to adiposity, through: DXA scan in eleven

studies [1, 10, 17–21, 23, 32, 34, 39], CT scan in five

studies [23, 24, 27, 30, 34], bioimpedance analysis (BIA) in

four studies [5, 25, 35, 38], or anthropometric parameters

(BMI, WC) in ten studies [5, 22, 27, 29–31, 33, 35–37].

The presence of sarcopenia was assessed through DXA

scan in the majority of the studies. In the remaining studies,

CT scan [23, 24, 30, 31], BIA [25, 29, 35, 36, 38] or

dynamometer test [5, 33, 37, 38] were used.

Discussion

The number of obese elderly subjects is increasing and

aging is physiologically associated with body composition

change characterized by increased fat mass and reduced

muscle mass. In some cases these phenomena are pro-

nounced, being responsible for the occurrence of a syn-

drome, the so-called sarcopenic obesity which is associated

to the worsening of physical disability, morbidity, and

mortality. Sarcopenia and obesity might act synergistically

on metabolic and functional impairments in the elderly

[27].

To date, just few papers provided clear and shared

diagnostic criteria of SO. In fact, in our review, criteria

adopted by single authors were only partially overlapping.

This is the reason why the reported prevalence varied

significantly among the study, and, obviously, a certain part

of subjects with SO was not detected, depending on the

criteria used (with important potential consequences in

terms of clinical and functional status).

One of the main obstacles is represented by the defini-

tion of SO, and especially whether it should be based only

on criteria of body composition [reduced muscle mass

(MM) and increased fat mass (FM)] or also functional

criteria should be taken into account. On the other hand,

obesity (as one of the two components of SO) is usually

defined merely according to fat mass or BMI, whereas in

the definition of sarcopenia, to the criterion of the reduced

FFM also muscle strength and functional impairment have

been added, hence required for diagnosis.

In the consensus by Cruz-Jentoft et al., the European

Working Group on Sarcopenia in Older People (EWGSOP)

[41] recommends to consider the presence of both low

muscle mass and low muscle function (strength or perfor-

mance). By this way, the EWGSOP further classifies

conceptual stages as ‘presarcopenia’, ‘sarcopenia’ and

‘severe sarcopenia’.

In the case of SO, it is likely that the same logical

pathway should be followed, even if, at present, no study

hypothesized a diagnosis of SO besides the simple evalu-

ation of body composition.

An implementation of this definition with muscle strength

and functional parameters will probably be more useful in

clinical practice. A wide range of tests is available for

physical performance evaluation, in particular in the elderly

population, including the short physical performance battery

Table 1 continued

References Sample Sarcopenia Obesity

Stenholm et al. [39] 930 elderly subjects from in CHIANTI study (Tuscany, Italy)

[65 years

Knee extensor

strength.

Anthropometrics (BMI)

Visser et al. [38] 325 patients admitted for elective coronary artery bypass grafting and/

or heart valve surgery

Handgrip strength

and BIA

BIA

Waters et al. [39] 206 community-dwelling older adults (65 years or older; 55 ? years

for Maori and Pacific Islanders) plus having an increased risk of

falling or having had at least one fall in the past 12 months

DXA DXA

DXA dual energy X-ray absorptiometry, CT computed tomography, BMI body mass index, WC waist circumference, BIA bioimpedance analysis

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Table 2 Reference values of body composition parameters for the definition of sarcopenic obesity

Reference Sarcopenia Obesity

Aubertin-Leheudreet al. [17]

MMI \14.30 kg/m2; FFMI: 1 SD lower than the MMI of a referencesample

FM [35 %

Auyeung et al. [18] Adiposity to muscle ratio (body weight or adiposity bearing on a unit of muscle mass could) equal to or greater than 0.75

Barbat-Artigaset al. [19]

Type I sarcopenia: ASM/ht2 1-2 SD below values for young adults(5.75–6.75 kg/m2)

FM [40 % obese individuals

Type II sarcopenia: ASM/ht2 \2SDs or more below 5.75 kg/m2

Baumgartner [1] ASM/ht2 \2 SD below the sex-specific mean for a young adultreference population

FM [than sex- and age specific median: 38 % forwomen and 27 % for men

Baumgartner et al.[10]

ASM/ht2 \2SD below mean of healthy young adults: \7.26 kg/m2 inmen and \5.45 kg/m2 in women

FM [40 % for women and [28 % for men

Bouchard et al. [20] ASM/ht2 \2SD below sex-specific mean for healthy young cohort:\6.29 kg/m2 in women and \8.51 kg/m2 in men

FM [35 % in women and [28 % in men

Cesari et al. [21] Lowest tertile of the residuals between ASM on FM and height(residuals of fat-adjusted ASM): 0.47 for the men and 2.79 for thewomen.

Age, gender and ethnic specific cut-offs for FMpreviously proposed by Gallagher et al. [40]

Chung et al. [22] ASM/Wt\1 SD below the mean of a reference group of healthy adultsaged 20–39 years: 32.5 % for men, 25.7 % for women

BMI [25 kg/m2

Kim et al. [23] ASM/Wt \1 SD below the sex-specific mean value for the youngreference group: 39.7 % in men and 34.1 % in women

Visceral fat area [100 cm2 in both men andwomen

Kohara et al. [24] CSA/Wt within 1SD of the distribution in reference subjects aged\50 years

Visceral fat area [100 cm2 in both men andwomen

Lu et al. [25] CSA/Wt within one standard deviation value of the CSA/BWdistribution in subjects aged, 50 years among

Visceral fat area [100 cm2 in both men andwomen

Levine andCrimmins [26]

ASM/Wt \2 SD below the mean of a young reference group: 25.72 %for males and 19.43 % for females

WC [102 cm for males and 88 cm for females

Lim et al. [27] ASM/Wt\1SD below mean reference of young cohort: 29.9 % for menand 25.1 % for women

Visceral fat area [100 cm2 in both men andwomen

Messier et al. [28] ASM/ht2 \6.44 kg/m2 and 5.05 kg/m2 respectively for class I and IIsarcopenia

BMI [27 kg/m2

Monteiro et al. [29] ASM/ht2 \1 SD of the sex-specific mean for young females BMI [25.5 kg/m2

Ochi et al. [30] Quadriceps muscle CSA/Wt \ 1SD value of the CSA distribution in ayoung reference group (independently for men and women)

Visceral fat area [100 cm2 in both men andwomen

Prado et al. [31] Sex-specific cut points for L3 muscle CSA adjusted by height definedby optimal stratification analysis cut points based on mortality:52.4 cm2/m2 for men and 38.5 cm2/m2 for women.

BMI [30 kg/m2

Rolland et al. [32] ASM/ht2 2 SD below the mean in a young female reference group:5.45 kg/m2

FM [60th percentile of study sample

Schrager et al. [33] Tertiles of muscle strength (grip strength): lowest sex-specific tertile Central obesity: waist circumference: upper sex-specific tertile

Global obesity: BMI [30 kg/m2

Seo et al. [34] ASM/ht2 1 SD below the sex-specific mean of a young reference group:6.75 kg/m2 for men and 4.96 kg/m2 for women

Visceral fat area [100 cm2 in both men andwomen

Siervo et al. [35] ASM/ht2 2SD below reference population: 6.76 kg/m2 BMI [30 kg/m2, WC [88 cm, FM [ 35 %, FMI[9.5 kg/m2

Srikanthan et al.[36]

ASM/Wt\2SD sex-specific, young adult (ages, 18–39) means: 31.0 %in men and 22.0 % in women

BMI [30 kg/m2

Stenholm et al. [5] Muscle strength: sex-specific quartiles FM and WC sex-specific quartiles; BMI: WHOcut-offs

Stenholm et al. [39] Lowest sex-specific tertile of knee extensor strength BMI [30 kg/m2

Visser et al. [38] FFM index\14.6 kgm2 for women, and 16.7 kgm2 for men; 8.3 kg/m2

for menFMI [11.8 kg/m2 for women

Handgrip strength \85 % of its age–sex standardized

Waters et al. [39] ASM/ht2 \7.2 kg/m2 in males and \5.4 kg/m2 in females FM C30 % in males and C40 % in females

ASM appendicular skeletal mass, ASM/ht2 relative skeletal muscle mass index, ASM/Wt ASM as a percentage of body weight, BMI body mass index,CSA cross-sectional area, CSA/Wt thigh muscle cross-sectional area corrected by body weight, FFMI fat-free mass index, FM fat mass, FMI fat massindex, MMI muscle mass index, SMI skeletal muscle index, WC waist circumference

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(SPPB), the usual gait speed, the 6-min walk test and the stair

climb power test [42]. Encompassing functional informa-

tion, this definition will be more responsive to the patient’s

clinical status and to the severity of the disease. Moreover, it

will also make easier to imagine the course of the nutritional

and rehabilitation treatment and to identify the outcomes to

be achieved. In fact, the increase in FM together with the

deterioration of lean body mass (with possible fatty infil-

tration) may lead to a progressive worsening of functional

parameters such as aerobic capacity, muscle strength,

walking speed, and ability to maintain balance.

In addition, in our view, a definition of sarcopenia based

on the reduction of muscle mass in ‘‘absolute’’ terms is

limited in the case of obesity and does not describe thor-

oughly the picture of obese subjects in terms of body

composition. Initially, at least in younger obese subjects,

the increase of fat mass is accompanied by a physiological

increase of muscle mass [43–46] which enables to main-

tain, for a relatively long time, a good metabolic control

and a satisfactory physical efficiency. Nevertheless, signs

of sarcopenia appear at an early stage in the obese subjects;

as a matter of fact, a relative and not an absolute reduction

of muscle mass is sufficient to determine a reduced func-

tional performance. An index of sarcopenia in obese sub-

jects based on a reduction in the ratio between measured

muscle mass and ideal (estimated) muscle mass is under

validation [47].

Other indices have been used in the literature to assess

muscle mass and fat mass. One of the most commonly used

indices for the definition of sarcopenia is the total appen-

dicular skeletal muscle (ASM) index: subjects included in

the lowest quantile group or -2SD values of a gender-spe-

cific distribution of muscle mass in a reference population

of young, healthy subjects as cut-off points are identified as

sarcopenic subjects while FFM has been adjusted to height

squared to take into account the differences in body size.

The adjustment for height squared has been the preferred

method but the adjustment for body weight has also been

applied. Subjects below the 50th calculated percentile for

FFMI are considered sarcopenic [11].

Another important issue in the identification of sarco-

penic obese subjects is represented by methods and tools to

be used for the assessment of body composition as well as

the choice of functional indicators. In research settings, two

imaging techniques have been used for estimating muscle

mass or fat mass [computed tomography (CT scan) and

magnetic resonance imaging (MRI)]; these techniques, and

to a lesser extent, dual energy X-ray absorptiometry

(DXA), are considered to be very precise imaging systems,

able to separate fat from other soft tissues in the body.

However, high cost, limited access to equipment in some

facilities and concerns about radiation exposure limit the

use of these whole-body imaging methods for routine

clinical practice. BIA may represent a valid alternative to

these methods in clinical practice being inexpensive, easy

to use and readily reproducible. BIA results, obtained

under standard conditions, have been found to correlate

well with gold standard techniques [48].

In some papers, the FFM evaluation has been coupled to

or replaced by the evaluation of muscle strength, especially

of lower limb strength [37] or more frequently handgrip

strength. These measures are relevant for gait and physical

function, and have a good correlation with clinical and

functional outcomes. Low cost, availability and easiness of

use make handgrip strength a valid parameter to be

assessed in clinical practice in addition to research settings.

On the other hand, it should be underlined that these

indicators cannot replace at all neither the body composi-

tion evaluation nor functional parameters.

Finally, the choice of threshold values needs to be dis-

cussed. Cut-off points depend on the measurement tech-

nique chosen and on the availability of reference studies.

Similarly to what happens for bone mineral density, a

normative population (healthy young adults) was used,

with cut-off points at two standard deviations below the

mean reference value. In the present review, the diverse

threshold values and methods adopted by different authors

make difficult the comparison of papers. It represents a

relevant limitation, given that in the research fieldwork

different intervention procedures need to be compared as

well as in clinical practice it is important to verify the

outcomes of interventions.

In conclusion, further epidemiological data are needed

to obtain good reference values for populations in different

countries and for different ethnicities.

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