Measurement in Physical Education and Exercise Science

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Predictive Validity of Handgrip Strength, Vertical

Jump Power, and Plank Time in the Identification
of Pediatric Sarcopenia

Fátima Baptista, Vera Zymbal & Kathleen F. Janz

To cite this article: Fátima Baptista, Vera Zymbal & Kathleen F. Janz (2022) Predictive Validity
of Handgrip Strength, Vertical Jump Power, and Plank Time in the Identification of Pediatric
Sarcopenia, Measurement in Physical Education and Exercise Science, 26:4, 361-370, DOI:
10.1080/1091367X.2021.1987242

To link to this article: https://doi.org/10.1080/1091367X.2021.1987242

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Published online: 19 Oct 2021.

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MEASUREMENT IN PHYSICAL EDUCATION AND EXERCISE SCIENCE
2022, VOL. 26, NO. 4, 361–370
https://doi.org/10.1080/1091367X.2021.1987242

Predictive Validity of Handgrip Strength, Vertical Jump Power, and Plank Time in
the Identification of Pediatric Sarcopenia
Fátima Baptistaa, Vera Zymbala, and Kathleen F. Janzb
a
Department of Sports and Health, CIPER, Faculdade de Motricidade Humana, Universidade de Lisboa, Lisbon, Portugal; bDepartment of Health
and Human Physiology, Department of Epidemiology, The University of Iowa, Iowa City, Iowa

ABSTRACT KEYWORDS
This study examined the predictive validity of musculoskeletal fitness tests for identifying sarcope­ Adolescent; body
nia in youth. The sample was 529 participants age 10 to 18 years. Indices included: total lean body composition; children;
mass (LBM) normalized for height (LBM index, LBMI, kg/m2), appendicular LBMI (aLBMI, kg/m2), and muscle; musculoskeletal
fitness
LBM to fat body mass (FBM) ratio (LBM/FBM). Lean and fat tissue were measured via DXA. The cutoff
value for sarcopenia was – 2.0 standard deviations ≤ mean for age and sex. Fitness was assessed
using handgrip, plank, and vertical jump tests. Variables were standardized using the lambda-mu-
sigma (LMS) method. By sex, analysis included the area under the curve (AUC), sensitivity (Se), and
specificity (Sp). The ROC curves for aLBMI was highly accurate (AUCs ≥ 0.90, Se and Sp = 86–88%) for
vertical jump and moderately accurate for handgrip (AUCs = 0.87–0.88, Se and Sp = 71–75%).
Fitness tests can be used to identify pediatric sarcopenia.

Introduction
Sarcopenia is a disease characterized by age-related
decreases of skeletal muscle mass and muscle
strength (Cruz-Jentoft & Sayer, 2019). The clinical
implications of this disease to the elderly have been
reported in different environments (community,
institutional, and hospital) and include the increased
risk of falling and illness, decreased ability to perform
activities of daily living, decreased cognitive ability,
and reduced quality of life (Bianchi et al., 2017).
Elderly people with sarcopenia also have a greater
probability of institutionalization, hospitalization,
hospital infection, extended duration of hospital
stays, complications associated with medical treat­
ments, and death (Cosqueric et al., 2006; Galli
et al., 2020; Hanna, 2015; Janssen, 2006; Levolger
et al., 2015). Prevalence estimates for sarcopenia
vary from 1–29% among elderly populations living
in communities and from 17– 33% among institutio­
nalized elderly adults (Cruz-Jentoft & Sayer, 2019).
These estimates are lower than those found in elderly
populations who are hospitalized, which is around
60% (Antunes et al., 2017). Prevalence estimates for
the elderly vary not only due to setting but also due
to sarcopenia assessment algorithms established by
different working groups (Mayhew et al., 2019).
Sarcopenia is largely attributable to aging; however
other causes have been identified. Secondary sarcopenia
can occur due to a disease, especially inflammatory dis­
eases, malignancies, or other diseases that cause cardiac,
respiratory, or renal insufficiency (Cruz-Jentoft et al.,
2019b). Physical inactivity and excessive sedentary beha­
viors contribute to the development of sarcopenia (Bauer
et al., 2019). Additionally, sarcopenia can progress due to
inadequate nutrition, particularly the ingestion/absorp­
tion of energy, protein, and vitamins C, D, and
E (Morley et al., 2011). Generally, the sarcopenia etiology
is multifactorial and characterizing an individual as hav­
ing primary or secondary sarcopenia is not reliable.
The modification of risk factors during adulthood,
especially late adulthood, has been the main strategy
for preventing sarcopenia (Denison et al., 2015). It is
assumed that muscle mass and muscle function in the
elderly is determined by the rate of their decline during
adulthood. However, there is evidence that the develop­
ment of sarcopenia can begin during childhood and
adolescence due to insufficient acquisition of muscle
mass, that is low peak muscle mass (Orsso et al., 2019).
At this time, a combination of proper nutrition and
strength exercise is the most common prevention strat­
egy for sarcopenia, regardless of age (Beaudart et al.,
2017; Damanti et al., 2019).

CONTACT Fátima Baptista fbaptista@fmh.ulisboa.pt Department of Sports and Health, CIPER, Faculdade de Motricidade Humana, Universidade de
Lisboa, Lisbon, Portugal
© 2021 The Author(s). Published with license by Taylor & Francis Group, LLC
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-
nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built
upon in any way.
362 F. BAPTISTA ET AL.
In addition to the likelihood that the onset of sarco­
penia development may occur before adulthood, sarco­
penia itself (the disease), is not limited to the elderly.
Sarcopenia is also present, at least, in youth with specific
pediatric pathologies. For example, pediatric studies on
sarcopenia have included individuals with liver, kidney
or intestinal insufficiency diseases, and malignancy
(Gilligan et al., 2020). These studies have generally
used different approaches, methods, and scores to define
sarcopenia in pediatric patients (Metzger et al., 2021).
Clinical outcomes associated with pediatric sarcopenia
include delayed growth, increased length of hospitaliza­
tion, and increased rate of re-admission (Merli, 2020). In
clinical conditions such as chronic liver disease, the
prevalence of pediatric sarcopenia can reach 40%
(Rezende et al., 2020). As in adults, the estimation of
prevalence is hampered by the lack of criterion for
assessment and reference values.
Despite the growing interest in pediatric sarcopenia,
the concept is not yet operationalized regarding identi­
fication criteria (Orsso et al., 2019). Advancement of
research in this area will enable practionners to better
recognize sarcopenia not only in pediatric patients with
chronic diseases but, perhaps, also in apparently healthy
pediatric populations. Advancement in defining sarco­
penia will also support prevention and treatment of the
mechanical and metabolic dysregulation which appears
to track into adulthood (Larissa True et al., 2021).
Therefore, the aim of this study was to examine the
predictive validity of musculoskeletal fitness using hand­
grip dynamometry, the isometric core plank test, and
vertical jump mechanography for the identification (of
pediatric sarcopenia. The study is innovative in its pur­
pose (screening) in the target population (apparently
healthy young people), and in its assessment procedures
(musculoskeletal fitness tests). We believe the use of
musculoskeletal fitness assessments to identify sarcope­
nia may have an advantage of feasibility and efficacy
since musculoskeletal fitness tests are easy to administer
as well as indicative of the amount of muscle and muscle
function. Therefore, they are a relatively complete repre­
sentation of healthy and unhealthy muscularity. Our
secondary aim was to develop reference values for the
assessment of pediatric sarcopenia in apparently healthy
youth.
Materials and methods
Participants
The sample consisted of 529 participants (249 girls and
280 boys, 97% white) from 10 to 18 years of age from the
4th to the 12th year grades, recruited from public
schools through their respective class directors. The
data were collected between September 2017 and
May 2018 by a group of evaluators trained for the
purpose. Informed consent was obtained from all guar­
dians. Musculoskeletal fitness was assessed in the school
and the health outcomes (sarcopenia) were assessed via
a dual-energy x-ray absorptiometry scan (DXA) at the
Exercise and Health Laboratory, University of Lisbon,
Portugal. Not all participants who underwent fitness
tests were available for the DXA scan (468 of the total
participants, 88.5%). More complete details for the
methods can be found in the (Janz et al., 2021) submis­
sion in this supplement. A general health status was
assessed through parental questionnaire (chronic illness,
medication, and injuries) and confirmed during the
laboratory visit. Heart disease (murmur and arrhythmia)
was reported in 3 participants, asthma in 17 participants
and prior bone fracture in 70 participants of the study.
These 90 participants were included in the study.
Musculoskeletal fitness
Handgrip strength (Handgrip, kg), maximum isometric
contraction for ~ 2 seconds, was assessed twice in each
hand using a dynamometer (Jamar, Lafayette, IN, USA).
The best result (kg) was used for data analysis. Peak
vertical jump power (VJ Power, W) was obtained from
a counter movement performed on a force platform
(Leonardo Mechanograph, Novotec Medical GmbH,
Germany). The participants assumed a jumping position
with their hands resting at the waist and their feet as
wide as the pelvis. Participants performed a practice
jump and two test jumps. The highest of the two
jumps was recorded as VJ Power, W to the nearest 1/
10th, and used for data analysis. Abdominal strength was
assessed using the plank test (Plank, s) in which the body
weight was supported by the toes and forearms. The test
was terminated when participants were unable to main­
tain posture or their pelvis moved up or down five or
more cm, measured using a ruler. The test was also
ended if participants remained in the plank position
for 3 minutes (highest score).
Sarcopenia
Three indices of sarcopenia were constructed from total
lean mass (LBM, kg) without bone mineral content and
total fat body mass (FBM, kg) measured using a whole-
body DXA scan (QDR Explorer, Hologic, Waltham,
MA, USA), post 3 hours fast. The sarcopenia indices
were: 1. LBM index (LBMI) normalized for body height
(kg/m2), 2. appendicular LBMI (aLBMI), i.e., the sum of
LBM of the upper and lower limbs normalized for body
 MEASUREMENT IN PHYSICAL EDUCATION AND EXERCISE SCIENCE 363

height (kg/m2), and 3. LBM to FBM ratio (LBM/FBM), Table 1. Characterization of the participants.
i.e., LBM normalized for FBM to minimize categoriza­ N Males N Females
tion based on individual compartment of lean mass or Age, y 280 13.79 (2.40) 249 13.76 (2.27)
Body Mass, kg 280 51.39 (13.75) 249 49.28 (10.09)*
fat mass. These indices are used to diagnose sarcopenia Body Height, cm 280 159.36 (13.45) 249 155.14 (9.23)**
in the adult population (Cruz-Jentoft & Sayer, 2019), in BMI, kg/m2 280 19.87 (3.05) 249 20.33 (3.08)
LBMI, kg/m2 252 14.03 (1.86) 216 12.99 (1.44)**
pediatric patients (Gilligan et al., 2020), or to analyze aLBMI, kg/m2 252 6.34 (0.96) 216 5.57 (0.70)**
sarcopenic obesity in children (Orsso et al., 2019). Lean Mass/ Fat Mass 252 1.46 (0.50) 216 0.92 (0.26)**
Handgrip, kg 280 29.76 (10.55) 249 25.12 (5.97)**
Standing height was measured with stadiometer (Seca VJ Power, W 280 2309.70 (902.81) 249 1923.81 (484.55)**
770, Hamburg, Germany) with subjects in underwear Plank, s 280 129.16 (54.41) 249 106.06 (48.75)**
and without shoes. * p < 0.05; ** p < 0.001: significant differences between males and females
For sarcopenia, the cutoff value stipulated for both
adults (Baumgartner et al., 1998) and for pediatric
patients (Metzger et al., 2021) was adopted. For pre- Age- and sex-specific reference values (median –
sarcopenia, −1SD was considered as a significant devia­ M) for lean tissue variables for the 3rd, 10th, 25th,
tion below normal to suggest potential risk and adopted. 50th, 75th, 90th, 97th centiles are presented in Table 2.
Therefore, sarcopenia and pre-sarcopenia were defined In general, total and appendicular LBMI increased
for the three indices as values ≤ −2.0 standard deviations with age in both males and females. The same
(SD) (3rd centile) and ≤ −1.0 SD (19th centile), respec­ occurred with LBM/FBM in males but not in females,
tively, for mean age and sex. where the peak of LBM in relation to FBM was
reached at ~ 12–13 years.
The cutoff values, the classification accuracy, and
Statistical analysis the odds ratios for the identification of sarcopenia
(Z-score ≤ −2.0) and pre-sarcopenia (Z-score ≤ −1.0)
Means and standard deviations were calculated to by Handgrip, VJ Power, and Plank are presented in
describe the distributional properties of variables. Tables 3–Tabe 5. When LBMI and aLBMI were the
Student’s t-test were used to compare male and female criteria, VJ Power and Handgrip were highly accurate
mean values. The lambda-mu-sigma method (LMS (AUC ≥ 0.90) or moderately accurate (AUC = 0.87 to
Chartmaker Pro version 2.45; Cole & Pan 2001) was 0.88) predictors of sarcopenia and moderately accurate
utilized to describe reference centiles values for the (AUC = 0.70 to 0.89) predictors of pre-sarcopenia
sarcopenia indices. Analyzes were performed to assess with the exception of Handgrip in females with the
the ability of each of the musculoskeletal fitness tests criterion of LBMI (AUC = 0.69). The Plank was
(Handgrip, VJ Power, and Plank) to identify sarcopenia moderately accurate for the identification of sarcope­
(≤ −2.0 SD) and pre-sarcopenia (≤ −1.0 SD) for each of nia (AUC = 0.87 to 0.88) and pre-sarcopenia (AUC =
the three indices, i.e., LBMI, aLBMI, LBM/FBM. These 0.73 to 0.74) only when the criterion was the LBM/
analyses included the area under the curve (AUC), sen­ FBM (p ≤ 0.001). The musculoskeletal test with the
sitivity (Se), specificity (Sp), and predictive odds ratios greatest discriminating power for sarcopenia in both
by logistic regression. From the cutoff values, three risk sexes was VJ Power with aLBMI as the criterion. The
zones were established – Desirable, Pre-sarcopenia, and sensitivity-specificity analysis indicated that the identi­
Sarcopenia. For this purpose, all variables (musculoske­ fication of sarcopenia (aLBMI ≤-2.0 SD) in partici­
letal tests and sarcopenia indices) were standardized pants corresponded to −0.6 SD for Handgrip in both
through LMS Charmaker for each sex and age group. sexes, −1.1 SD of VJ Power in males, and −0.8 SD VJ
The SPSS program (Version 24 for Windows; SPSS, Power in females. The corresponding percentiles are
Chicago, IL, USA) was used for the remaining analyses. the P28 for Handgrip for both males and females and
The significance value was set at p ≤ 0.05 for all analyzes. the P16 (males) and P18 (females) for VJ Power.
Table 4
Results Using the LBM/FBM for the identification of sarco­
penia (≤-2.0 SD), the cutoff value for Plank was −0.5 SD
Table 1 presents a description of the participants includ­ (P35) for males and −1.0 SD (P18) for females. Using
ing mean, SD values for the musculoskeletal fitness tests aLBMI as the sarcopenia criterion, a 1.0 SD increase in
and sarcopenia indices. Males showed higher indices for Handgrip corresponded to a 79% reduction in the
total and appendicular lean mass than females, and also chances of sarcopenia identification in females and
a higher lean to fat body mass ratio. Males performed 80% in males. Whereas, an increase of 1.0 SD in VJ
better than females on all fitness tests. Power corresponded to a 91% reduction in the chances
364 F. BAPTISTA ET AL.

Table 2. Age- and sex-specific reference percentiles for lean tissue variables.
LBMI, kg/m2
Males Females
M M
Age, y L S 3rd 10th 25th 50th 75th 90th 97th L S 3rd 10th 25th 50th 75th 90th 97th
10 −0.554 0.077 10.3 10.8 11.4 12.0 12.6 13.3 14.0 0.939 0.101 9.1 9.8 10.6 11.4 12.1 12.9 13.7
11 −0.395 0.078 10.6 11.1 11.7 12.3 13.0 13.7 14.5 0.632 0.101 9.7 10.4 11.2 12.0 12.9 13.7 14.6
12 −0.236 0.080 10.8 11.3 11.9 12.6 13.3 14.0 14.8 −0.009 0.103 10.5 11.2 12.0 12.8 13.6 14.6 15.6
13 0.138 0.085 11.2 11.9 12.6 13.3 14.1 14.9 15.7 −0.544 0.099 10.9 11.5 12.3 13.1 13.9 14.9 16.0
14 0.903 0.088 11.8 12.6 13.5 14.3 15.1 16.0 16.8 −0.752 0.096 11.0 11.7 12.4 13.2 14.0 15.0 16.1
15 1.208 0.087 12.2 13.1 14.0 14.9 15.7 16.6 17.4 −0.793 0.094 11.1 11.7 12.4 13.2 14.0 15.0 16.1
16 1.020 0.086 12.7 13.5 14.4 15.3 16.2 17.1 17.9 −1.055 0.094 11.2 11.8 12.5 13.3 14.2 15.1 16.3
17 0.517 0.085 13.3 14.1 15.0 15.9 16.8 17.7 18.7 −2.160 0.092 11.9 12.5 13.1 13.8 14.6 15.7 17.0
18 0.103 0.084 13.7 14.5 15.3 16.2 17.1 18.1 19.1 −3.592 0.084 12.6 13.1 13.6 14.2 15.0 16.1 17.5
aLBMI, kg/m2
Males Females
M M
Age, y L S 3rd 10th 25th 50th 75th 90th 97th L S 3rd 10th 25th 50th 75th 90th 97th
10 0.790 0.088 4.3 4.6 4.9 5.2 5.6 5.9 6.2 1.841 0.124 3.5 4.0 4.5 4.9 5.3 5.7 6.0
11 0.734 0.088 4.5 4.8 5.1 5.4 5.8 6.1 6.4 0.468 0.117 4.0 4.4 4.7 5.1 5.5 5.9 6.4
12 0.696 0.088 4.6 5.0 5.3 5.6 5.9 6.3 6.6 −0.552 0.110 4.5 4.8 5.2 5.6 6.0 6.5 7.0
13 0.773 0.090 4.9 5.3 5.6 6.0 6.4 6.7 7.1 −0.763 0.109 4.6 4.9 5.2 5.6 6.1 6.5 7.1
14 1.255 0.094 5.3 5.7 6.1 6.5 7.0 7.4 7.8 −0.781 0.108 4.6 4.9 5.2 5.6 6.1 6.6 7.1
15 1.453 0.096 5.5 5.9 6.4 6.9 7.3 7.7 8.1 −0.808 0.108 4.6 4.9 5.3 5.6 6.1 6.6 7.1
16 1.337 0.097 5.6 6.1 6.6 7.1 7.5 7.9 8.4 −0.824 0.107 4.6 4.9 5.3 5.7 6.1 6.6 7.2
17 1.119 0.096 5.9 6.3 6.8 7.3 7.7 8.2 8.7 −0.788 0.106 4.8 5.1 5.4 5.8 6.3 6.8 7.4
18 0.975 0.096 6.0 6.5 6.9 7.4 7.9 8.4 8.8 −0.608 0.106 4.9 5.2 5.6 6.0 6.5 7.0 7.5
LBM/FBM
Males Females
M M
Age, y L S 3rd 10th 25th 50th 75th 90th 97th L S 3rd 10th 25th 50th 75th 90th 97th
10 0.172 0.308 0.54 0.68 0.84 1.04 1.27 1.54 1.86 −0.014 0.234 0.46 0.53 0.62 0.73 0.85 1.00 1.17
11 0.287 0.308 0.55 0.70 0.88 1.09 1.33 1.60 1.91 0.254 0.255 0.52 0.63 0.75 0.89 1.06 1.24 1.45
12 0.498 0.307 0.59 0.77 0.98 1.22 1.48 1.77 2.08 0.218 0.264 0.54 0.66 0.80 0.95 1.13 1.33 1.57
13 0.670 0.307 0.60 0.82 1.06 1.32 1.60 1.90 2.21 0.185 0.265 0.54 0.66 0.79 0.95 1.13 1.34 1.57
14 0.828 0.298 0.65 0.91 1.19 1.47 1.77 2.07 2.39 0.125 0.266 0.54 0.65 0.78 0.94 1.12 1.32 1.57
15 1.106 0.280 0.72 1.06 1.39 1.71 2.03 2.34 2.65 −0.003 0.268 0.52 0.63 0.75 0.90 1.07 1.28 1.53
16 1.301 0.267 0.71 1.10 1.44 1.77 2.07 2.37 2.65 −0.110 0.273 0.51 0.61 0.72 0.87 1.04 1.26 1.53
17 1.350 0.264 0.70 1.10 1.45 1.77 2.07 2.36 2.63 −0.279 0.285 0.49 0.58 0.69 0.83 1.01 1.24 1.54
18 1.461 0.256 0.68 1.09 1.44 1.76 2.05 2.32 2.58 −0.444 0.296 0.47 0.55 0.66 0.80 0.98 1.23 1.58
L: lambda (skewness), which models departure from normality; M: mu (median), which represents how lean tissue variables change with age; S: sigma
(coefficient of variation) which models the spread of reference values and adjust for non-uniform dispersion.

Table 3. Cutoff values for handgrip strength, to identify sarcopenia (Zscore ≤ −2) and pre-sarcopenia (Zscore ≤ −1), classification
accuracy, and respective sensitivity and specificity, according to LBMI, aLBMI, and LM/FM.
Z-score Handgrip Z-score Handgrip percentilea AUC (95% CI) p-value Se Sp Odds Ratio (95% CI)b
Males LBMI −2.0 −0.8 20 0.91 (0.85,0.98) ≤0.001 87.5 80.5 0.15 (0.06,0.40)
−1.0 −0.4 35 0.78 (0.71,0.85) ≤0.001 71.4 74.4 0.34 (0.23,0.50)
aLBMI −2.0 −0.6 28 0.87 (0.77,0.97) ≤0.001 71.4 74.3 0.20 (0.08,0.49)
−1.0 −0.4 35 0.75 (0.68,0.83) ≤0.001 66.7 72.5 0.39 (0.26,0.57)
LM/FM −2.0 - - 0.55 (0.28,0.81) 0.702 - - -
−1.0 - - 0.53 (0.43,0.62) 0.545 - - -
Females LBMI −2.0 −0.6 30 0.69 (0.47,0.91) ≤0.001 71.4 72.2 0.52 (0.24,1.11)
−1.0 −0.2 42 0.79 (0.72,0.86) ≤0.001 67.5 69.3 0.29 (0.18,0.45)
aLBMI −2.0 −0.6 28 0.88 (0.80,0.97) ≤0.001 75.0 75.0 0.19 (0.08,0.47)
−1.0 −0.2 42 0.70 (0.72,0.86) 0.087 67.5 69.3 0.28 (0.18,0.44)
LM/FM −2.0 - - 0.52 (0.25,0.79) 0.868 - - -
−1.0 - - 0.56 (0.45,0.66) 0.290 - - -
a
Percentiles for corresponding Z-scores for normal (0,1) distribution.
b
OR (95% CI) from logistic regression.

of sarcopenia identification in females and 96% in males. When Using the reference criterion of aLBMI for Handgrip
using the criterion of LBM/FBM, an increase of 1.0 SD in Plank and VJ Jump but LBM/FBM for Plank, specific muscu­
corresponded to a 79% decrease in the chances of sarcopenia loskeletal fitness scores sorted by sex and age for the
identification in females and 87% in males. categorization of Desirable, Pre-sarcopenia, and
 MEASUREMENT IN PHYSICAL EDUCATION AND EXERCISE SCIENCE 365

Table 4. Cutoff values for vertical jump power, to identify sarcopenia (Zscore ≤ −2) and pre-sarcopenia (Zscore ≤ −1), classification
accuracy, and respective sensitivity and specificity, according to LBMI, aLBMI, and LM/FM.
Z-score VJ Power Z-score VJ Power percentilea AUC (95% CI) p-value Se Sp Odds Ratio (95% CI)b
Males LBMI −2.0 −1.2 14 0.92 (0.85,0.99) ≤0.001 87.5 87.7 0.09 (0.02,0.31)
−1.0 −0.5 32 0.87 (0.82,0.91) ≤0.001 79.6 80.8 0.16 (0.09,0.28)
aLBMI −2.0 −1.1 16 0.95 (0.89,1.00) ≤0.001 85.7 85.7 0.04 (0.01,0.24)
−1.0 −0.6 28 0.89 (0.85,0.93) ≤0.001 84.4 83.6 0.12 (0.07,0.23)
LM/FM −2.0 - - 0.29 (0.28,0.42) 0.084 - - -
−1.0 0.1 53 0.39 (0.31,0.49) 0.028 42.6 42.9 1.39 (1.00,1.91)
Females LBMI −2.0 −0.8 18 0.87 (0.73,1.00) ≤0.001 85.7 86.1 0.18 (0.07,0.47)
−1.0 −0.5 33 0.89 (0.84,0.95) ≤0.001 80.0 80.1 0.08 (0.03,0.18)
aLBMI −2.0 −0.8 17 0.94 (0.88,1.00) ≤0.001 87.5 87.5 0.09 (0.03,0.28)
−1.0 −0.4 35 0.86 (0.81,0.92) ≤0.001 75.0 77.7 0.14 (0.07,0.27)
LM/FM −2.0 - - 0.39 (0.19,0.59) 0.340 - - -
−1.0 - - 0.43 (0.33,0.54) 0.190 - - -
a
Percentiles for corresponding Z-scores for normal (0,1) distribution.
b
OR (95% CI) from logistic regression

Table 5. Cutoff values for the prone plank test, to identify sarcopenia (Zscore ≤ −2) and pre-sarcopenia (Zscore ≤ −1), classification
accuracy, and respective sensitivity and specificity, according to LBMI, aLBMI, and LM/FM.
Z-score Plank Z-score Plank percentilea AUC (95% CI) p-value Se Sp Odds Ratio (95% CI)b
Males LBMI −2.0 - - 0.57 (0.44,0.70) 0.481 - - -
−1.0 - - 0.48 (0.40,0.57) 0.781 - - -
aLBMI −2.0 - - 0.59 (0.42,0.76) 0.421 - - -
−1.0 - - 0.49 (0.40,0.58) - - -
LM/FM −2.0 −0.5 35 0.87 (0.75,0.99) 0.002 66.7 66,7 0.13 (0.04,0.44)
−1.0 −0.3 40 0.74 (0.66,0.82) ≤0.001 68.1 69.3 0.38 (0.26,0.54)
Females LBMI −2.0 0.5 68 0.24 (0.05,0.42) 0.017 28.6 31.1 2.78 (1.05,7.36)
−1.0 - - 0.47 (0.37,0.57) 0.551 - - -
aLBMI −2.0 - - 0.54 (0.26,0.81) 0.734 - - -
−1.0 - - 0.52 (0.42,0.63) 0.635 - - -
LM/FM −2.0 −1.0 18 0.88 (0.78,0.99) 0.002 83.3 83.3 0.21 (0.07,0.63)
−1.0 −0.5 39 0.73 (0.64,0.82) ≤0.001 62.2 65.9 0.40 (0.26,0.60)
a
Percentiles for corresponding Z-scores for normal (0,1) distribution.
b
OR (95% CI) from logistic regression

Table 6. Handgrip strength (kg, left panel), VJ power (W, central panel), and plank endurance time (s, right panel) reference values for
the identification of sarcopenia, pre-sarcopenia and desirable zones in boys and girls from 10 to 18 years old, reference aLBMI for
handgrip strength and VJ power and LBM/FBM for plank endurance time.
Males Handgrip Males VJ Power Males Plank
Age Desirable Pre-Sarcopenia Sarcopenia Age Desirable Pre-Sarcopenia Sarcopenia Age Desirable Pre-Sarcopenia Sarcopenia
10 >17.1 17.1–16.4 <16.4 10 >1174 1174–1030 <1030 10 >79 79–69 <69
11 >18.1 18.1–17.4 <17.4 11 >1300 1300–1175 <1175 11 >75 75–65 <65
12 >20.5 20.5–19.8 <19.8 12 >1401 1401–1305 <1305 12 >96 96–86 <86
13 >22.3 22.3–21.5 <21.5 13 >1596 1596–1378 <1378 13 >102 102–93 <93
14 >28.9 28.9–27.7 <27.7 14 >2063 2063–1788 <1788 14 >130 130–122 <122
15 >32.8 32.8–31.3 <31.3 15 >2523 2523–2241 <2241 15 >131 131–122 <122
16 >33.9 33.9–32.4 <32.4 16 >2504 2504–2223 <2223 16 >124 124–117 <117
17 >40.0 40.0–38.5 <38.5 17 >3021 3021–2754 <2754 17 >147 147–141 <141
18 >39.3 39.3–38.8 <38.0 18 >3075 3075–2778 <2778 18 >145 145–139 <139
Females Handgrip Females VJ Power Females Plank
10 >16.0 16.0–14.5 <14.5 10 >1209 1209–1081 <1081 10 >62 62–36 <36
11 >17.5 17.5–16.1 <16.1 11 >1274 1274–1156 <1156 11 >79 79–50 <50
12 >21.7 21.7–20.4 <20.4 12 >1626 1626–1485 <1485 12 >73 73–45 <45
13 >24.5 24.5–23.1 <23.1 13 >1745 1745–1596 <1596 13 >78 78–56 <56
14 >25.7 25.7–24.2 <24.2 14 >1891 1891–1753 <1753 14 >90 90–62 <62
15 >27.2 27.2–25.4 <25.4 15 >1948 1948–1785 <1785 15 >93 93–71 <71
16 >28.8 28.8–27.5 <27.5 16 >2076 2076–1970 <1970 16 >94 94–73 <73
17 >29.4 29.4–27.7 <27.7 17 >2215 2215–2064 <2064 17 >86 86–63 <63
18 >29.1 29.4–26.6 <26.6 18 >2118 2118–1982 <1982 18 >106 106–79 <79
366 F. BAPTISTA ET AL.
Sarcopenia are provided in Table 6. In general, for both
males and females, scores for placement in the Desirable
zone increased until age 17 years.
Discussion
The results of this study indicate that musculoskeletal
fitness assessments can be used to identify pediatric
sarcopenia in apparently healthy youth. However, the
accuracy of the assessments varied depending on the
lean tissue criterion. For both males and females, the
different musculoskeletal fitness tests demonstrated
acceptable predictive capacity with 50 to 80% sensitivity
and specificity (Handgrip and Plank) or good predictive
capacity with sensitivity and specificity > 80% (VJ
Power). The AUCs of the fitness tests indicated moder­
ately to highly accurate validity.
Several studies have systematically reviewed the
importance of musculoskeletal fitness during childhood
and adolescence for health and for future (adult) health
(Foster et al., 2020; García-Hermoso et al., 2019;
Henriksson et al., 2019; De Lima et al., 2020; Smith
et al., 2014; Torres-Costoso et al., 2020). These studies
emphasized the development of musculoskeletal fitness
screening approaches linked to clinically-relevant cri­
teria. The most obvious criteria are clinical assessments
of low LBM (DXA) or low fat-free mass (BIA) though
neither directly assess muscle mass (Buehring et al.,
2018). As more research identifies muscle mass as
a factor in metabolic and mechanical dysregulation,
there is an increased need to prevent and treat its sub­
optimal accrual in the pediatric population. This is par­
ticularly important for those children and adolescents
with specific clinical conditions (Merli et al., 2020; Ooi
et al., 2020; Orsso et al., 2019b). However, accurate
identification must come before prevention and treat­
ment and reference values for apparently healthy youth
are needed for comparison and interpretation.
In adults, the most commonly proposed body com­
position variable for the study of sarcopenia is aLBMI
determined with DXA (Guglielmi et al., 2016). This
makes sense since appendicular LBM is primarily skele­
tal muscle mass. Baumgartner and colleagues recom­
mended a cutoff value for reduced lean mass of – 2.0
SD (P 20) using percentile data from healthy young
adults (18–40 years) which is interpreted similarly to
a bone scan T score (Baumgartner et al., 1998). This
interpretation can be problematic since it lacks predic­
tive power to specific health outcomes and populations.
Our study is among the first to provide criterion-
referenced cutoffs and the strategies we used could
serve as a model for future studies including adult
populations.
Recently in pediatrics, greater attention has been
directed to the role of skeletal muscle mass to health.
Large-scale assessments to create reference values have
been conducted using DXA (Guo et al., 2016; Kelly et al.,
2009; Kim et al., 2016; Marwaha et al., 2017; Weber et al.,
2013) and, also, bio-electrical impedance (BIA)
(Chiplonkar et al., 2017; Gontarev et al., 2020;
McCarthy et al., 2014; Steffl et al., 2017). Different defi­
nitions (e.g., LBMI, LBM/FBM) have been proposed
though, in general, the same cut point (−2.0 SD) is
used (Metzger et al., 2021). The normalization of the
LBM to the FBM is consistently proposed in order to
overcome deviations from healthy body composition
based solely on individualized compartments (lean
mass or fat mass). The use of indices that include FBM
and LBM or fat-free mass (and vice versa) has been
examined predominantly in the context of sarcopenic
obesity, seeking to investigate excessive adiposity (obe­
sity) and insufficient muscularity (sarcopenia) at the
same time, i.e., load-capacity model (Roubenoff, 2004).
These indices contrast the metabolic load of adiposity
and the metabolic capacity of muscularity (Siervo et al.,
2015). The Plank test, which primarily assesses core
muscle activation and function (Choi et al., 2019), may
provide a unique criterion for screening metabolic
abnormalities associated with body composition.
In a recent systematic review of this literature, sarco­
penia was not considered as a clinical nor criterion out­
come (Fraser et al., 2021). However, two studies were
identified that included sarcopenic obesity assessed by
bioimpedance and presented cutoff values for handgrip
strength adjusted for the BMI for the assessment of
musculoskeletal fitness (in)sufficiency in youth
(Gontarev et al., 2020; Steffl et al., 2017). The methodol­
ogy used in these studies does not allow direct compar­
isons with our results. However, Saint-Maurice et al.
(2018) used similar data processing including LMS-
derived standardized scores to develop handgrip
strength cut-points for the identification of low risk
(desirable) amounts of total body bone mass. The Saint-
Maurice study used two samples, i.e., healthy youth from
the Midwest USA to develop cut-points and healthy
adolescents from Zaragoza, Spain to test the cut-points.
Their proposed cutoffs for low risk handgrip strength as
it pertains to bone mass were nearly the same as our
desirable cut-points for handgrip strength as it pertains
to muscularity (aLBMI). For example, our desirable
handgrip score for 10 yr old males was >17.1 and their
low risk score was >17.3 kg . Our desirable handgrip
score for 10 yr old females was >16.0 and their low risk
score was >16.5 kg. At age 18 years, the scores were
>39.3/42.8 kg for males and >29.1/28.7 kg for females,
respectively. These similar results, despite differences in
 MEASUREMENT IN PHYSICAL EDUCATION AND EXERCISE SCIENCE
samples and outcomes, suggest the possibility of
a handgrip cutoff to represent the functional muscle-
bone unit rather than only discreet musculoskeletal
outcomes.
In addition to a lack of racial diversity (our sam­
ple was 97% white), a limitation of this investigation
is the sample, whose phenotype of body composi­
tion and physical fitness may differ from that of
participants from other regions/countries. For
example, the LMS parameters published by Weber
et al. (2013), used DXA-determined data from the
National Health and Nutrition Examination Survey
(NHANES) in U. S. children and adolescents from
1999 to 2004. Our sample has a LBMI Z score 0.5
SD (girls) and 0.6 SD (boys) lower than the average
of the NHANES sample. This difference indicates
population differences and/or equipment differences
since NHANES used the QDR 4500 NHANES and
our study used the QDR Explorer. The musculoske­
letal fitness values that we report are similar or
higher to scores published on North American sam­
ples, with the exception of handgrip strength for
boys (Bohannon et al., 2017; Ervin et al., 2014;
Gabel et al., 2016; Perna et al., 2016). These differ­
ences suggest our reference values should be used
with caution for dissimilar populations. However,
the similarity of desirable scores for handgrip
strength between our study and that of Saint-
Maurice et al. (2018), leads us to believe in the
possibility of common reference for the functional
muscle-bone unit.
The strengths of this study include: (i) the use of
DXA to assess sarcopenia; (ii) defining sarcopenia
using different lean mass indices; (iii) the evaluation
of musculoskeletal fitness with an exploration of the
different types of force (strength, power, endurance),
and body regions (upper limbs, lower limbs, trunk);
(iv) the sample size with its sex- and age-
representativeness.
In the end, this is the first study to operationalize
the identification of sarcopenia through musculos­
keletal fitness in an apparently healthy pediatric
population. Handgrip strength, vertical jump
power, and plank endurance were all valid markers
for the identification of sarcopenia in children and
adolescent. Future research should confirm our
results.
Acknowledgements
Fátima Baptista was partly supported by the Fundação para
a Ciência e Tecnologia, under Grant UIDB/00447/2020 to
CIPER - Centro Interdisciplinar do Estudo da Performance
367
Humana (unit 447), Portugal, and by a grant from the Cooper
Institute, Dallas, Texas, USA.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Funding
This work was supported by the Cooper Institute, Dallas, TX
[Special Award]; CIPER - Centro Interdisciplinar de Estudo da
Performance Humana [Grant UIDB/00447/2020].
References
Antunes, A. C., Araújo, D. A., Veríssimo, M. T., & Amaral, T.
F. (2017). Sarcopenia and hospitalisation costs in older
adults: A cross-sectional study. Nutrition & Dietetics: the
journal of the Dietitians Association of Australia, 74(1), 46–
50. https://doi.org/10.1111/1747–0080.12287
Bauer, J., Morley, J. E., Schols, A., Ferrucci, L., Cruz-Jentoft,
A. J., Dent, E., Baracos, V. E., Crawford, J. A., Doehner, W.,
Heymsfield, S. B., Jatoi, A., Kalantar-Zadeh, K.,
Lainscak, M., Landi, F., Laviano, A., Mancuso, M.,
Muscaritoli, M., Prado, C. M., Strasser, F., Von
Haehling, S., & Anker, S. D. (2019). Sarcopenia: A time
for action. an SCWD position paper. Journal of Cachexia,
Sarcopenia and Muscle, 10(5), 956–961. https://doi.org/10.
1002/jcsm.12483
Baumgartner, R. N., Koehler, K. M., Gallagher, D., Romero, L.,
Heymsfield, S. B., Ross, R. R., Garry, P. J., &
Lindeman, R. D. (1998). Epidemiology of sarcopenia
among the elderly in New Mexico. American Journal of
Epidemiology, 147(8), 755–763. https://doi.org/10.1093/
oxfordjournals.aje.a009520
Beaudart, C., Dawson, A., Shaw, S. C., Harvey, N. C.,
Kanis, J. A., Binkley, N., Reginster, J. Y., Chapurlat, R.,
Chan, D. C., Bruyère, O., Rizzoli, R., Cooper, C., &
Dennison, E. M., & IOF-ESCEO Sarcopenia Working
Group. (2017). Nutrition and physical activity in the pre­
vention and treatment of sarcopenia: Systematic review.
Osteoporosis International, 28(6), 1817–1833. https://doi.
org/10.1007/s00198-017-3980-9
Bianchi, L., Abete, P., Bellelli, G., Bo, M., Cherubini, A.,
Corica, F., Di Bari, M., Maggio, M., Manca, G. M.,
Rizzo, M. R., Rossi, A. P., Landi, F., & Volpato, S., &
GLISTEN Group Investigators. (2017). Prevalence and clin­
ical correlates of sarcopenia, identified according to the
EWGSOP definition and diagnostic algorithm, in hospita­
lized older people: The GLISTEN Study. The Journals of
Gerontology. Series A, 72(11), 1575–1581. https://doi.org/
10.1093/gerona/glw343
Bohannon, R. W., Wang, Y. C., Bubela, D., & Gershon, R. C.
(2017). Handgrip strength: A population-based study of
norms and age trajectories for 3- to 17-year-olds. Pediatric
Physical Therapy, 29(2), 118–123. https://doi.org/10.1097/
PEP.0000000000000366
Buehring, B., Siglinsky, E., Krueger, D., Evans, W.,
Hellerstein, M., Yamada, Y., & Binkley, N. (2018).
Comparison of muscle/lean mass measurement methods.
368 F. BAPTISTA ET AL.
Correlation with functional and biochemical testing.
Osteoporosis International, 29(3), 675–683. https://doi.org/
10.1007/s00198-017-4315-6
Chiplonkar, S., Kajale, N., Ekbote, V., Mandlik, R.,
Parthasarathy, L., Borade, A., Patel, P., Patel, P.,
Khadilkar, V., & Khadilkar, A. (2017). Reference centile
curves for body fat percentage, fat-free mass, muscle
mass and bone mass measured by bioelectrical impe­
dance in Asian Indian children and adolescents. Indian
Pediatrics, 54(12), 1005–1011. https://doi.org/10.1007/
s13312-017-1201-4
Choi, J. H., Kim, D. E., & Cynn, H. S. (2019). Comparison of
trunk muscle activity between traditional plank exercise
and plank exercise with isometric contraction of ankle
muscles in subjects with chronic low back pain. Journal
of Strength and Conditioning Research. Advance online
publication. https://doi.org/10.1519/JSC.
0000000000003188
Cole, T. & Pan, H. (2001) LMS program. London, UK:
Medical Research Council.https://www.healthforallchil
dren.com/
Cosquéric, G., Sebag, A., Ducolombier, C., Thomas, C., Piette,
F., & Weill-Engerer, S. (2006). Sarcopenia is predictive of
nosocomial infection in care of the elderly. The British
Journal of Nutrition,96(5), 895–901. https://doi.org/10.
1017/bjn20061943
Cruz-Jentoft, A. J., Bahat, G., Bauer, J., Boirie, Y., Bruyère, O.,
Cederholm, T., Cooper, C., Landi, F., Rolland, Y., Sayer, A. A.,
Schneider, S. M., Sieber, C. C., Topinkova, E.,
Vandewoude, M., Visser, M., & Zamboni, M., & Writing
Group for the European Working Group on Sarcopenia in
Older People 2 (EWGSOP2), and the Extended Group for
EWGSOP2. (2019b). Sarcopenia: Revised European consensus
on definition and diagnosis. Age and Ageing, 48(1), 16–31.
https://doi.org/10.1093/ageing/afy169
Cruz-Jentoft, A. J., & Sayer, A. A. (2019). Sarcopenia. The
Lancet, 393(10191), 2636–2646. https://doi.org/10.1016/
S0140-6736(19)31138-9
Damanti, S., Azzolino, D., Roncaglione, C., Arosio, B.,
Rossi, P., & Cesari, M. (2019). Efficacy of nutritional inter­
ventions as stand-alone or synergistic treatments with exer­
cise for the management of sarcopenia. Nutrients, 11(9),
1991. https://doi.org/10.3390/nu11091991
De Lima, T. R., Martins, P. C., Torre, G. L., Mannocci, A.,
Silva, K. S., & Silva, D. (2020). Association between muscle
strength and risk factors for metabolic syndrome in chil­
dren and adolescents: A systematic review. Journal of
Pediatric Endocrinology & Metabolism, 34(1), 1–12.
https://doi.org/10.1515/jpem-2020-0135
Denison, H. J., Cooper, C., Sayer, A. A., & Robinson, S. M.
(2015). Prevention and optimal management of sarcopenia:
A review of combined exercise and nutrition interventions
to improve muscle outcomes in older people. Clinical
Interventions in Aging, 10, 859–869. https://doi.org/10.
2147/CIA.S55842
Ervin, R. B., Fryar, C. D., Wang, C. Y., Miller, I. M., &
Ogden, C. L. (2014). Strength and body weight in US
children and adolescents. Pediatrics, 134(3), e782–e789.
https://doi.org/10.1542/peds.2014-0794
Foster, H. E., Scott, C., Tiderius, C. J., & Dobbs, M. B., &
Members of the Pediatric Global Musculoskeletal Task
Force. (2020). Improving musculoskeletal health for chil­
dren and young people - A ‘call to action’. Clinical
Rheumatology, 34(5), 101566.
Fraser, B. J., Rollo, S., Sampson, M., Magnussen, C. G.,
Lang, J. J., Tremblay, M. S., & Tomkinson, G. R. (2021).
Health-related criterion-referenced cut-points for muscu­
loskeletal fitness among youth: A systematic review. Sports
Medicine (Auckland, N.Z.). Advance online publication.
https://doi.org/10.1007/s40279-021-01524-8
Gabel, L., Macdonald, H. M., Nettlefold, L., Race, D., &
McKay, H. A. (2016). Reference data for jumping mechan­
ography in Canadian children, adolescents and young
adults. Journal of Musculoskeletal & Neuronal Interactions,
16(4), 283–295.
Galli, A., Colombo, M., Carrara, G., Lira Luce, F., Paesano, P. L.,
Giordano, L., Bondi, S., Tulli, M., Mirabile, A., De Cobelli, F., &
Bussi, M. (2020). Low skeletal muscle mass as predictor of post­
operative complications and decreased overall survival in locally
advanced head and neck squamous cell carcinoma: The role of
ultrasound of rectus femoris muscle. European Archives of Oto-
rhino-laryngology, 277(12), 3489–3502. https://doi.org/10.1007/
s00405-020-06123-3
García-Hermoso, A., Ramírez-Campillo, R., & Izquierdo, M.
(2019). Is muscular fitness associated with future health bene­
fits in children and adolescents? A systematic review and
meta-analysis of longitudinal studies. Sports Medicine, 49(7),
1079–1094. https://doi.org/10.1007/s40279-019-01098-6
Gilligan, L. A., Towbin, A. J., Dillman, J. R.,
Somasundaram, E., & Trout, A. T. (2020). Quantification
of skeletal muscle mass: Sarcopenia as a marker of overall
health in children and adults. Pediatric Radiology, 50(4),
455–464. https://doi.org/10.1007/s00247-019-04562-7
Gontarev, S., Jakimovski, M., & Georgiev, G. (2020). Using
relative handgrip strength to identify children at risk of
sarcopenic obesity. Uso de la fuerza relativa de la
empuñadura para identificar a los niños en riesgo de obe­
sidad sarcopénica. Nutricion Hospitalaria, 34(3), 490–496.
https://doi.org/10.20960/nh.02977
Guglielmi, G., Ponti, F., Agostini, M., Amadori, M.,
Battista, G., & Bazzocchi, A. (2016). The role of DXA in
sarcopenia. Aging Clinical and Experimental Research, 28
(6), 1047–1060. https://doi.org/10.1007/s40520-016-0589-3
Guo, B., Wu, Q., Gong, J., Xiao, Z., Tang, Y., Shang, J.,
Cheng, Y., & Xu, H. (2016). Relationships between the
lean mass index and bone mass and reference values of
muscular status in healthy Chinese children and
adolescents. Journal of Bone and Mineral Metabolism, 34
(6), 703–713. https://doi.org/10.1007/s00774-015-0725-8
Hanna, J. S. (2015). Sarcopenia and critical illness: A deadly
combination in the elderly. JPEN. Journal of Parenteral and
Enteral Nutrition, 39(3), 273–281. https://doi.org/10.1177/
0148607114567710
Henriksson, H., Henriksson, P., Tynelius, P., & Ortega, F. B.
(2019). Muscular weakness in adolescence is associated with
disability 30 years later: A population-based cohort study of
1.2 million men. British Journal of Sports Medicine, 53(19),
1221–1230. https://doi.org/10.1136/bjsports-2017-098723
 MEASUREMENT IN PHYSICAL EDUCATION AND EXERCISE SCIENCE
Janssen, I. (2006). Influence of sarcopenia on the development
of physical disability: The Cardiovascular Health Study.
Journal of the American Geriatrics Society, 54(1), 56–62.
https://doi.org/10.1111/j.1532-5415.2005.00540.x
Janz, K. F., Baptista, F., Ren, S., Zhu, W., Laurson, K. L.,
Mahar, M. T., Pavlovic, A., & Welk, G. J. (2021).
Associations among musculoskeletal fitness assessment
and health outcomes: The Lisbon Study for the develop­
ment and evaulation of musculoskeletal fitness standards in
youth. Journal of Measurement in Physical Education and
Exercise Science. (submitted in this suppliement).
Kelly, T. L., Wilson, K. E., & Heymsfield, S. B. (2009). Dual
energy X-ray absorptiometry body composition reference
values from NHANES. PloS One, 4(9), e7038. https://doi.
org/10.1371/journal.pone.0007038
Kim, K., Hong, S., & Kim, E. Y. (2016). Reference values of
skeletal muscle mass for Korean children and adolescents
using data from the Korean National Health and Nutrition
Examination Survey 2009-2011. PloS One, 11(4), e0153383.
https://doi.org/10.1371/journal.pone.0153383
Larissa True, E. M., Martin, K. A., Pfeiffer, S. R., Siegel, C. F.,
Branta, J. H., & Seefeldt, V. (2021). Tracking of physical fitness
components from childhood to adolescence: A longitudinal
study. Measurement in Physical Education and Exercise Science,
25(1), 22–34. https://doi.org/10.1080/1091367X.2020.1729767
Levolger, S., Van Vledder, M. G., Muslem, R., Koek, M.,
Niessen, W. J., De Man, R. A., De Bruin, R. W., &
Ijzermans, J. N. (2015). Sarcopenia impairs survival in
patients with potentially curable hepatocellular carcinoma.
Journal of Surgical Oncology, 112(2), 208–213. https://doi.
org/10.1002/jso.23976
Marwaha, R. K., Garg, M. K., Bhadra, K., Mahalle, N., Mithal, A.,
& Tandon, N. (2017). Lean body mass and bone health in
urban adolescents from Northern India. Indian Pediatrics, 54
(3), 193–198. https://doi.org/10.1007/s13312-017-1029-y
Mayhew, A. J., Amog, K., Phillips, S., Parise, G.,
McNicholas, P. D., De Souza, R. J., Thabane, L., &
Raina, P. (2019). The prevalence of sarcopenia in
community-dwelling older adults, an exploration of differ­
ences between studies and within definitions: A systematic
review and meta-analyses. Age and Ageing, 48(1), 48–56.
https://doi.org/10.1093/ageing/afy106
McCarthy, H. D., Samani-Radia, D., Jebb, S. A., &
Prentice, A. M. (2014). Skeletal muscle mass reference curves
for children and adolescents. Pediatric Obesity, 9(4),
249–259. https://doi.org/10.1111/j.2047-6310.2013.00168.x
Merli, M. (2020). Pediatric sarcopenia: Exploring a new concept in
children with chronic liver disease. Jornal De Pediatria, 96(4),
406–408. https://doi.org/10.1016/j.jped.2019.08.001
Merli, M. (2020) Pediatric sarcopenia: Exploring a new concept in
children with chronic liver disease. Jornal de Pediatria, 96(4),
406–408. https://doi.org/10.1016/jjped201908001
Metzger, G. A., Carsel, A., Sebastião, Y. V., Deans, K. J., &
Minneci, P. C. (2021). Does sarcopenia affect outcomes in
pediatric surgical patients? A scoping review. Journal of
Pediatric Surgery, S0022-3468(21)00029–4. Advance online
publication. https://doi.org/10.1016/j.jpedsurg.2021.01.009
369
Morley, J. E., Abbatecola, A. M., Argiles, J. M., Baracos, V.,
Bauer, J., Bhasin, S., Cederholm, T., Coats, A. J.,
Cummings, S. R., Evans, W. J., Fearon, K., Ferrucci, L.,
Fielding, R. A., Guralnik, J. M., Harris, T. B., Inui, A.,
Kalantar-Zadeh, K., Kirwan, B. A., Mantovani, G., &
Muscaritoli, M., & Society on Sarcopenia, Cachexia and
Wasting Disorders Trialist Workshop. (2011).
Sarcopenia with limited mobility: An international
consensus. Journal of the American Medical Directors
Association, 12(6), 403–409. https://doi.org/10.1016/j.
jamda.2011.04.014
Ooi, P. H., Thompson-Hodgetts, S., Pritchard-Wiart, L.,
Gilmour, S. M., & Mager, D. R. (2020). Pediatric
Sarcopenia: A paradigm in the overall definition of malnutri­
tion in children? Journal of Parenteral and Enteral Nutrition,
44(3), 407–418. https://doi.org/10.1002/jpen.1681
Orsso, C. E., Tibaes, J., Oliveira, C., Rubin, D. A., Field, C. J.,
Heymsfield, S. B., Prado, C. M., & Haqq, A. M. (2019). Low
muscle mass and strength in pediatrics patients: Why should
we care? Clinical Nutrition, 38(5), 2002–2015. https://doi.
org/10.1016/j.clnu.2019.04.012
Orsso, C. E., Tibaes, J., Rubin, D. A., Field, C. J., Heymsfield, S. B.,
Prado, C. M., & Haqq, A. M. (2019b). Metabolic implications
of low muscle mass in the pediatric population: A critical
review. Metabolism: Clinical and Experimental, 99, 102–112.
https://doi.org/10.1016/j.metabol.2019.153949
Perna, F., Coa, K., Troiano, R., Lawman, H. G., Wang, C.,
Li, Y., Moser, R. P., Ciccolo, J. T., Comstock, B. A., &
Kraemer, W. J. (2016). Muscular grip strength estimates of
the U.S population from the National Health and Nutrition
Examination Survey 2011-2012. Journal of Strength and
Conditioning Research, 30(3), 867–874. https://doi.org/10.
1519/JSC.0000000000001104
Rezende, I., Conceição-Machado, M., Souza, V. S., Santos, E.,
& Silva, L. R. (2020). Sarcopenia in children and adolescents
with chronic liver disease. Jornal de Pediatria, 96(4), 439–
446. https://doi.org/10.1016/j.jped2019.02.005
Rezende, I., Conceição-Machado, M., Souza, V. S., Santos, E.,
& Silva, L. R. (2020). Sarcopenia in children and adolescents
with chronic liver disease. Jornal De Pediatria, 96(4),
439–446. https://doi.org/10.1016/j.jped.2019.02.005
Roubenoff, R. (2004). Sarcopenic obesity: The confluence of
two epidemics. Obesity Research, 12(6), 887–888. https://
doi.org/10.1038/oby.2004.107
Saint-Maurice, P. F., Laurson, K., Welk, G. J.,
Eisenmann, J., Gracia-Marco, L., Artero, E. G.,
Ortega, F., Ruiz, J. R., Moreno, L. A., Vicente-
Rodriguez, G., & Janz, K. F. (2018). Grip strength cut­
points for youth based on a clinically relevant bone
health outcome. Archives of Osteoporosis, 13(1), 92.
https://doi.org/10.1007/s11657-018-0502-0
Siervo, M., Prado, C. M., Mire, E., Broyles, S., Wells, J. C.,
Heymsfield, S., & Katzmarzyk, P. T. (2015). Body composi­
tion indices of a load-capacity model: Gender- and
BMI-specific reference curves. Public Health Nutrition, 18
(7), 1245–1254. https://doi.org/10.1017/
S1368980014001918
370 F. BAPTISTA ET AL.
Smith, J. J., Eather, N., Morgan, P. J., Plotnikoff, R. C.,
Faigenbaum, A. D., & Lubans, D. R. (2014). The health
benefits of muscular fitness for children and adolescents:
A systematic review and meta-analysis. Sports Medicine,
44(9), 1209–1223. https://doi.org/10.1007/s40279-014-
0196-4
Steffl, M., Chrudimsky, J., & Tufano, J. J. (2017). Using relative
handgrip strength to identify children at risk of sarcopenic
obesity. PloS One, 12(5), e0177006. https://doi.org/10.1371/
journal.pone.0177006
Torres-Costoso, A., López-Muñoz, P., Martínez-Vizcaíno, V., Álvarez-
Bueno, C., & Cavero-Redondo, I. (2020). Association btween mus­
cular strength and bone health from children to young adults:
A systematic review and meta-analysis. Sports Medicine, 50(6),
1163–1190. https://doi.org/10.1007/s40279-020-01267-y
Weber, D. R., Moore, R. H., Leonard, M. B., & Zemel, B. S. (2013). Fat
and lean BMI reference curves in children and adolescents and their
utility in identifying excess adiposity compared with BMI and
percentage body fat. American Journal of Clinical Nutrition, 98(1),
49–56. https://doi.org/10.3945/ajcn.112.053611