What is the 2025 Asian Working Group for Sarcopenia (AWGS) algorithm for case‑finding, diagnosis, and management of sarcopenia in adults aged 65 years and older?

AWGS 2025 Sarcopenia Algorithm

Diagnostic Framework

The 2025 Asian Working Group for Sarcopenia (AWGS) has simplified sarcopenia diagnosis to require only concurrent low muscle mass AND low muscle strength, with physical performance now serving as an outcome measure rather than a diagnostic criterion. 1

Key Updates from Previous Versions

• The diagnostic age range has been expanded to include middle-aged adults (50-64 years) with validated thresholds, moving beyond the previous focus on adults ≥65 years. 1
• The algorithm now emphasizes a life-course approach to muscle health promotion rather than solely disease diagnosis. 1
• AWGS 2025 aligns with the Global Leadership Initiative in Sarcopenia (GLIS) while providing Asia-specific guidance. 1

Case-Finding (Screening) Pathway

Community Setting

Begin screening with one of three validated tools to identify individuals at risk before proceeding to diagnostic assessment: 2

• Calf circumference: <34 cm in men, <33 cm in women 2
• SARC-F questionnaire: score ≥4 2
• SARC-CalF (combined tool): score ≥11 2

For community-dwelling Korean older adults specifically, use calf circumference in men (AUC 0.657) and SARC-CalF in women (AUC 0.631) as these demonstrate superior diagnostic accuracy. 3

Hospital/Clinical Setting

Use a separate algorithm beginning with the same screening tools (calf circumference, SARC-F, or SARC-CalF) but proceed more rapidly to comprehensive assessment given higher baseline risk. 2

Diagnostic Assessment

Step 1: Measure Muscle Strength (Required)

Low muscle strength is defined as: 2

• Handgrip strength <28 kg for men 2
• Handgrip strength <18 kg for women 2

Step 2: Measure Muscle Mass (Required)

Low muscle mass cutoffs using height-adjusted indices: 2

• Dual-energy X-ray absorptiometry (DXA): <7.0 kg/m² in men, <5.4 kg/m² in women 2
• Bioimpedance analysis (BIA): <7.0 kg/m² in men, <5.7 kg/m² in women 2

Sarcopenia is definitively diagnosed when BOTH low muscle strength AND low muscle mass are present concurrently. 1, 2

Step 3: Assess Physical Performance (Outcome Measure)

Physical performance is no longer required for diagnosis but serves to stratify severity and guide prognosis: 1

• 6-meter walk speed <1.0 m/s 2
• Short Physical Performance Battery (SPPB) score ≤9 2
• 5-time chair stand test ≥12 seconds 2

"Possible Sarcopenia" Category

For primary care and community health promotion settings, "possible sarcopenia" can be identified by low muscle strength OR low physical performance alone, enabling earlier lifestyle interventions without requiring muscle mass measurement. 2

This category is specifically designed for resource-limited settings where DXA or BIA may not be immediately available. 2

Management Algorithm

First-Line Intervention

Implement resistance training 2-3 times per week, which produces approximately 1.5 kg gain in muscle mass over 12 weeks. 4, 5

Combine resistance training with: 4, 5

• Aerobic activity to improve insulin sensitivity 4
• Weight-bearing exercises to prevent bone loss 4

Nutritional Intervention (Concurrent with Exercise)

Ensure daily protein intake >1.0 g/kg body weight, distributed throughout the day with 20-30 g per meal from leucine-rich protein sources. 4, 5

Avoid energy-restriction diets during active inflammation or illness, as this accelerates muscle loss. 4, 5

Multimodal Approach

The AWGS 2025 consensus emphasizes multimodal interventions combining resistance exercise with nutritional supplementation as the evidence-based standard. 1

This approach addresses sarcopenia's multifactorial etiology—inadequate nutrition, physical inactivity, micronutrient deficiencies, and age-related physiologic changes—simultaneously for superior outcomes. 4

Integration with WHO ICOPE Framework

The AWGS 2025 framework leverages the WHO Integrated Care for Older People (ICOPE) implementation for enhanced case-finding through natural overlap between muscle health and ICOPE's intrinsic capacity domains (cognition, mobility, sensory function, psychological health, vitality). 1

This integration recognizes skeletal muscle's cross-talk with brain, bone, adipose tissue, and immune systems, emphasizing muscle health as vital for healthy longevity. 1

Critical Pitfalls to Avoid

• Do not focus solely on weight loss in older adults with obesity without addressing muscle preservation, as this accelerates sarcopenia. 4
• Do not neglect resistance training—it is essential and cannot be replaced by aerobic exercise alone. 4, 5
• Seven days of bedrest results in 1 kg loss of lean leg muscle mass in older adults; maintain activity during hospitalizations. 4, 5
• Do not implement the AWGS 2019 algorithm when AWGS 2025 is available, as the simplified two-component diagnostic approach (muscle mass + strength only) improves clinical utility. 1