# Prevalence and impact of sarcopenia in patients with inflammatory bowel diseases: A prospective cohort study

Solène Dermine, T Bazin, Fatimé Adam Hassan, Johanna Bettolo, L Billiauws, J Bourdillel, Clément Bresteau, Olivier Corcos, Myriam El Khatib, Ashiq Mohamed Gouse, et al.

► To cite this version:

Solène Dermine, T Bazin, Fatimé Adam Hassan, Johanna Bettolo, L Billiauws, et al. Prevalence and impact of sarcopenia in patients with inflammatory bowel diseases: A prospective cohort study. Clinics and Research in Hepatology and Gastroenterology, 2025, 49 (4), pp.102555-102555. 10.1016/j.clinre.2025.102555. hal-05033743

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Original article

# Prevalence and impact of sarcopenia in patients with inflammatory bowel diseases: A prospective cohort study

<figure><img src="image_2.png" /></figure>

Solène Dermine<sup>a, *</sup>, Thomas Bazin<sup>a, b</sup>, Fatimé Adam Hassan<sup>c</sup>, Johanna Bettolo<sup>a</sup>,
Lore Billiauws<sup>a, d</sup>, Justine Bourdillel<sup>a</sup>, Clément Bresteau<sup>a</sup>, Olivier Corcos<sup>a, d</sup>, Myriam El khatib<sup>a</sup>,
Ashiq Mohamed Gouse<sup>a</sup>, Coralie Hutinet<sup>a</sup>, Alexandre Nuzzo<sup>a, d</sup>, Francisca Joly<sup>a, d</sup>

## ARTICLE INFO

### Keywords:

- Sarcopenia

- Myopenia

- Probable sarcopenia

- Malnutrition

- Inflammatory bowel disease

- Crohn's disease

- Ulcerative colitis

- Impedancemetry

## ABSTRACT

**Background:** Inflammatory bowel disease (IBD) patients with sarcopenia are at increased morbidity risk. The aim of this study was to assess the prevalence of sarcopenia in IBD outpatients using both morphological and functional criteria.

**Methods:** In this prospective cohort study, all IBD patients admitted to the day hospital unit between March 01 and 31, 2023 were included. Muscle mass and function were evaluated using bioelectrical impedance analysis and handgrip strength measurement, respectively. Probable sarcopenia was defined as reduced handgrip strength (<16-27 kg). Myopenia was defined by a low appendicular muscle mass index (<5.5-7 kg/m²). Sarcopenia was diagnosed based on the coexistence of reduced muscle strength and muscle mass. Disease activity, therapeutic changes, hospitalizations, and IBD-related surgeries were assessed at month 6.

**Results:** Sixty patients with either Crohn's disease (CD, 52%) or ulcerative colitis (48%), with a median age of 37 years (interquartile range [IQR]: 28-54), were included. Fifty-five percent were women. Most patients were in remission (67%, n = 40). In CD patients, the involvement was ileocolic (48%), ileal (35%), or colonic (16%). A history of IBD-related digestive surgery was noted in 30% of cases. The median body mass index [BMI] was 24 (IQR: 21-27). The prevalence of sarcopenia, probable sarcopenia, and myopenia was 10%, 18%, and 20%, respectively. Sarcopenic patients were significantly older (59 vs 36 years, p = 0.01), had a longer disease duration (20 vs 8 years, p = 0.003), were more likely to have associated joint inflammation (27% vs 6%, p = 0.01) and CD (80% vs 49%, p = 0.36). Myopenia was significantly associated with a history of surgery (67% vs 21%, p = 0.004) and a lower BMI (21 vs 24, p = 0.001).

**Conclusion:** In this prospective cohort of IBD outpatients, 10% and 20% of patients had sarcopenia and myopenia, respectively. Screening for sarcopenia therefore seems essential in this population, including in stable outpatients in remission who do not meet malnutrition criteria and in overweight patients, as according to the literature, sarcopenia is associated with poorer clinical outcomes and increased postoperative complications. Interventional studies are needed to assess the impact of multidisciplinary treatment of sarcopenia on quality of life and disease progression.

## Introduction

Sarcopenia is characterized by a progressive and generalized loss of muscle mass and strength, commonly associated with aging but can also

complicate various chronic diseases. It results from a combination of factors, including malnutrition, systemic inflammation, and reduced physical activity. The clinical consequences of sarcopenia are significant: in the elderly, as it increases the risk of falls, fractures, loss of

<footnote><sup>a</sup> Department of Gastroenterology and Nutritional Support, Center for Intestinal Failure, Reference Centre for Rare Disease MarDI, AP-HP Beaujon Hospital, University Paris, France</footnote>

<footnote><sup>b</sup> Infection & Inflammation, UMR 1173, Inserm, UVSQ/Université Paris Saclay, Montigny-le-Bretonneux, France</footnote>

<footnote><sup>c</sup> Assistance Publique-Hôpitaux de Paris, Hopitaux Universitaires Henri Mondor, Département de Biochimie-Pharmacologie-Biologie Moléculaire-Génétique Médicale, Créteil, France</footnote>

<footnote><sup>d</sup> Hôpital Bichat, Laboratory for Vascular Translational Science, Paris, France</footnote>

<footnote>* Corresponding author at: Department of Gastroenterology, Beaujon Hospital, Clichy-la-Garenne, 100 Bd du Général Leclerc, 92110, Clichy, France.
E-mail address: solene.dermine@aphp.fr (S. Dermine).</footnote>
functional independence, and is associated with higher mortality [1].

Sarcopenia was first described by Rosenberg in 1988 as a loss of muscle mass in the elderly. The current definition has since been extended to include chronic diseases and refined by adding the criterion of loss of muscle strength in addition to the loss of muscle mass [1]. The muscle mass can be assessed using various methods, including dual X-ray absorptiometry (DXA) to assess the appendicular skeletal muscle mass (SMM), bioelectrical impedance analysis (BIA) to assess the total body SMM, and magnetic resonance imaging (MRI) or computed tomography (CT) to measure the cross-sectional area of skeletal muscle at the third lumbar vertebra (L3). The muscle strength can be assessed using the grip strength or chair stand test [1].

Inflammatory bowel disease (IBD) encompasses a group of multi-factorial digestive disorders in which intestinal homeostasis is disrupted, leading to dysregulation of the intestinal immune system. IBD includes Crohn's disease (CD) and ulcerative colitis (UC), both characterized by recurrent abdominal pain, bloody stools, and weight loss. The incidence of these conditions is steadily rising in industrialized countries [2]. The inflammatory process in IBD leads to intestinal absorption disorders, systemic inflammation, and complications such as strictures, fistulas, and abscesses. The frequent need for intestinal resection further exacerbates metabolic disturbances. These conditions are also associated with a significant decline in quality of life and chronic fatigue, which reduces physical activity. The combination of these factors, which activate muscle protein degradation pathways and inhibit skeletal muscle protein synthesis, increases the risk of developing sarcopenia in IBD patients [3]. Sarcopenia can therefore be considered an extra-intestinal manifestation of IBD [4].

A meta-analysis has revealed a high prevalence of sarcopenia in IBD, estimated at 52 % in CD and 37 % in UC [5], only based on the assessment of the muscle mass (skeletal muscle index [SMI] at L3 level on MRI or CT-scan). Recent studies assessing the prevalence of sarcopenia in IBD based on European Working Group on Sarcopenia recommendations (EWGSOP) recommendations have estimated its occurrence to range from 2 % to 30 % [6–10]. Sarcopenia is related to a higher incidence of major postoperative complications [5] and an increased likelihood of having to undergo surgery [11,12]. A systematic screening for sarcopenia in IBD patients therefore appears very important, as this condition is both common and associated with poor outcomes.

However, there is a significant heterogeneity in the literature regarding the assessment of sarcopenia, with an emphasis on the assessment of the muscle mass without considering the muscle function. In addition, there is significant variability within the patients included in terms of disease activity, treatments administered and surgical history. To date, only one study has assessed the prevalence of sarcopenia in an outpatient IBD population. Sarcopenia is likely underestimated due to the younger age of this population and the relative absence of holistic management in outpatients.

The aim of this study was to prospectively assess the prevalence of sarcopenia in an outpatient IBD population using both morphological and functional criteria, according to EWGSOP recommendations [1,13].

# Methods

## Patients

All consecutive IBD patients admitted to the day hospital in the gastroenterology department of Beaujon Hospital, a tertiary referral center in Clichy, France, over a 1-month period (between March 01 and 31, 2023), were included. Patients with short bowel syndrome were excluded. Medical data were recorded prospectively. Baseline demographics were collected, including the age, gender, weight, height, and body mass index (BMI). Disease-specific features such as the location (according to the Montreal classification) [14], extra-intestinal manifestations, a perianal involvement, current and previous treatments, and prior surgeries were also documented. Clinical disease

activity was assessed using the Harvey-Bradshaw Index (HBI) for CD and the partial Mayo score for UC. Remission was defined by a HBI <4 [15] or a partial Mayo score ≤1 [16]. Biological values were collected retrospectively and included the C-reactive protein, vitamin D, albumin and fecal calprotectin levels. When available, the endoscopic activity was assessed using the Crohn's Disease Endoscopic Index (CDEIS) and the Rutgeerts score (for patients who underwent ileal surgery) for CD, and the Ulcerative Colitis Endoscopic Index (UCEIS) and the endoscopic Mayo score for UC.

## Nutritional status assessment

Sarcopenia is diagnosed based on the presence of both a loss of muscle strength and a loss of muscle mass. Isolated loss of muscle strength is referred to as probable sarcopenia, while isolated loss of muscle mass is called myopenia [13].

The muscle strength was assessed using a Carym® digital dynamometer to measure the handgrip strength. The muscle mass was assessed using a Bodystat®1500MDD (Bodystat, Douglas, Isle of Man) dual-frequency impedance meter (BIA) according to the manufacturer's instructions. The fat-free mass index (FFMI) was calculated by dividing the fat-free mass by the squared height, and muscle quality was determined using phase angle. All assessments (muscle strength and mass) were performed by the same operator (FAH).

Probable sarcopenia was defined by a handgrip strength of <16 kg for women and 27 kg for men.

Myopenia was defined by an appendicular muscle mass index (AMMI) of <5.7 kg/m² for women and 7 kg/m² for men, or a FFMI of <15 kg/m² for women and 17 kg/m² for men. The presence of both probable sarcopenia and myopenia was used to define sarcopenia [1,17, 18].

During the assessment, the weight, the weight loss beyond 6 months, the BMI and the last albumin level measured less than one month earlier were collected. Global Leadership Initiative in Malnutrition (GLIM) criteria were used to diagnose disease-related malnutrition (DRM) according to global nutritional guidelines [19].

## Outcomes

Patients were followed at month 6 and the disease clinical activity was reassessed. IBD-related surgery or hospitalization as well as any therapeutic change were recorded.

## Statistical analysis

Continuous data are presented as a median with interquartile range (IQR), while categorical data are presented as proportions. The study population was divided into two groups based on the diagnosis of sarcopenia. The differences between the two groups were investigated to identify factors associated with sarcopenia. To assess variable distribution between the groups, a Shapiro-Wilk test was used to test normality. Based on the results of this test, either the Student's t-test for independent samples (parametric) or the Wilcoxon-Mann-Whitney test (non-parametric) was used. Correlations between variables were assessed using the Spearman method. The significance level (α) was set at 5 %.

The hospital reports indicate that the collection and processing of anonymized clinical data was permitted unless the patient objected. This article is presented in accordance with the STROBE reporting checklist.

# Results

Table 1 shows patients' demographics and clinical characteristics. Sixty patients, with a median age of 37 years (28–54), were included in the study. There were 55 % of women. Among them, 52 % had CD and 48 % had UC that had been diagnosed 9 years (4–17) earlier. Most of them were in remission (67 %, n = 40). A history of IBD-related digestive
<table><caption>**Table 1**
Demographics and clinical characteristics of IBD patients (n = 60).</caption><tbody><tr><td>Gender (F/M ratio)</td><td>1.2</td></tr><tr><td>Age (median (IQR)), years</td><td>37 (28–54)</td></tr><tr><td>Disease duration (median (IQR)), years</td><td>9 (4–17)</td></tr><tr><td>Prior IBD-related abdominal surgery, %</td><td>30</td></tr><tr><td>Tobacco use, %</td><td>15</td></tr><tr><td>Joint inflammation, %</td><td>17</td></tr><tr><td>CRP level (median (IQR)), mg/L</td><td>2.4 (0.5–5.6)</td></tr><tr><td>Fecal calprotectin level (median (IQR)), µg/g</td><td>49 (14–281)</td></tr><tr><td><strong>Crohn's disease, %</strong></td><td><strong>52</strong></td></tr><tr><td>L1</td><td>35</td></tr><tr><td>L2</td><td>16</td></tr><tr><td>L3</td><td>48</td></tr><tr><td>HBI (median (IQR))</td><td>3 (1.5–4.5)</td></tr><tr><td>Clinical remission</td><td>58</td></tr><tr><td>CDEIS (median (IQR))</td><td>0 (0–0)</td></tr><tr><td>Rutgeerts score >1 (6 patients with scores available)</td><td>83</td></tr><tr><td><strong>Ulcerative colitis, %</strong></td><td><strong>48</strong></td></tr><tr><td>E1</td><td>7</td></tr><tr><td>E2</td><td>41</td></tr><tr><td>E3</td><td>52</td></tr><tr><td>Partial Mayo score (median (IQR))</td><td>0 (0–1)</td></tr><tr><td>Clinical remission</td><td>76</td></tr><tr><td>UCEIS (median (IQR))</td><td>1 (0–5)</td></tr><tr><td>Endoscopic Mayo score (median (IQR))</td><td>1 (0–2.8)</td></tr><tr><td><strong>Advanced therapy, %</strong></td><td><strong>97</strong></td></tr><tr><td>TNFα inhibitor</td><td>61</td></tr><tr><td>ustekinumab</td><td>14</td></tr><tr><td>vedolizumab</td><td>25</td></tr><tr><td>Overal clinical remission</td><td>67</td></tr></tbody></table>

Variables are presented as percentages unless specified otherwise. F/M: female/male. IQR: interquartile range. HBI: Harvey-Bradshaw Index. IBD phenotypes are expressed according to the Montreal classification. TNF: tumor necrosis factor; UCEIS: Ulcerative Colitis Endoscopic Index. IBD activity at month 6: therapeutic change, hospitalization, surgery, fecal calprotectin level >250 µg/g, endoscopic activity.

surgery was noted in 30 % of cases. Thirteen patients had received corticosteroid therapy in the past year. Biological therapies administered included infliximab and adalimumab (61 %), vedolizumab (25 %), or ustekinumab (14 %). Patients with CD had an ileocolic (48 %), ileal (35 %), or colonic (16 %) involvement. Patients with UC had an E1 (7 %), E2 (41 %), or E3 (52 %) involvement.

The prevalence of sarcopenia, probable sarcopenia and myopenia was 10 %, 18 % and 20 %, respectively (Fig. 1). The median BMI was 24 kg/m² (IQR 21–27). Patients’ nutritional characteristics are presented in Table 2.

In this cohort, 30 % of patients were overweight, and 8 % were obese. Fifteen per-cent of patients (9/60) had a DRM according to GLIM: 6 and 3 moderate and severe malnutrition respectively.

The factors associated with sarcopenia are presented in Table 3. Sarcopenic patients were significantly older (60 vs 36 years, *p* = 0.006), had IBD for longer (18 vs 9 years, *p* = 0.005), and showed associated joint inflammation (27 % vs 6 %, *p* = 0.01), and sarcopenia tended to be more frequently associated with CD (80 % vs 49 %, *p* = 0.36). Two patients with sarcopenia had a BMI greater than 25. The phase angle was significantly lower in patients with sarcopenia (6 % vs 67 %, *p* = 0.03). There were no significant differences in disease activity scores, type of biologics, BMI, or albumin, CRP and vitamin D levels between sarcopenic and non-sarcopenic patients. Use of corticoids in the past year was not associated with a higher rate of sarcopenia. The presence of joint inflammation was not associated with the diagnosis of myopenia or probable sarcopenia. Myopenia was significantly associated with a history of surgery (67 % vs 21 %, *p* = 0.004), a lower BMI (21 kg/m² vs 24 kg/m², *p* = 0.001) and a more clinically active disease at month 6 (50 % vs 21 %, *p* = 0.04 after adjustment for the age, gender and disease activity at baseline). Myopenia indices strongly correlated with handgrip values (*r* = 0.7, *p* < 0.001). None of the data collected was associated with the clinical outcomes during the follow-up.

<figure><img src="image_3.png" /><figcaption>**Fig. 1.** Patients’ nutritional status. Venn diagram representing the proportions of patients according to the nutritional diagnosis. Green: probable sarcopenia (18 %); blue: myopenia (20 %); red: sarcopenia (10 %). Created with BioVenn [20].</figcaption></figure>

<table><caption>**Table 2**
Patients’ nutritional characteristics.</caption><tbody><tr><td>BMI (median (IQR)), kg/m²</td><td>24 (21–27)</td></tr><tr><td>Serum albumin level (median (IQR)), g/L</td><td>41 (39–44)</td></tr><tr><td>Vitamin D level (median (IQR)), nmol/L</td><td>44 (34–67)</td></tr><tr><td><strong>Nutritional parameters</strong></td><td></td></tr><tr><td>Handgrip (median (IQR)), kg</td><td>29 (22–39)</td></tr><tr><td>AMMI (median (IQR))</td><td>8 (8–10)</td></tr><tr><td>FFMI (median (IQR))</td><td>18 (16–20)</td></tr><tr><td>Phase angle (median (IQR)),</td><td>6.9 (5.9–8.6)</td></tr><tr><td><strong>Nutritional status</strong></td><td></td></tr><tr><td>Myopenia (%)</td><td>20</td></tr><tr><td>Probable sarcopenia (%)</td><td>18</td></tr><tr><td>Sarcopenia (%)</td><td>10</td></tr></tbody></table>

Values are presented as medians (IQR) unless specified otherwise. BMI: body mass index. CRP: C-reactive protein. AMMI: appendicular muscle mass index. FFMI: fat-free mass index.

## Discussion

In this prospective cohort of 60 ambulatory IBD patients followed in our day hospital unit, the prevalence of sarcopenia was 10 %. Myopenia and probable sarcopenia were diagnosed in 20 % and 18 % of patients, respectively. Sarcopenia was more frequently observed in older patients, in patients with a longer disease duration, and in patients with joint manifestations.

The prevalence of sarcopenia in our population was lower than the rates reported in the most recent meta-analysis, which included both conditions (CD or UC), diseases states (remission or refractory), and patients settings (inpatient or outpatient). This discrepancy could be due to several factors. First, our patients were outpatients, whose disease is generally less active than that of inpatients, as indicated by their low clinical activity scores, and they were also younger. Second, as noted by Liu et al., there is a lack of standardized criteria for diagnosing
<table><caption>**Table 3**
Factors associated with sarcopenia.</caption><thead><tr><th></th><th>Sarcopenia (n = 6)</th><th>No sarcopenia (n = 54)</th><th>p-value</th></tr></thead><tbody><tr><td>Female gender, %</td><td>67</td><td>54</td><td>NS</td></tr><tr><td>Age (median (IQR)), years</td><td>60 (57–63)</td><td>36 (28–50)</td><td>0.006</td></tr><tr><td>BMI (median (IQR)), kg/m<sup>2</sup></td><td>22 (20–25)</td><td>24 (22–27)</td><td>NS</td></tr><tr><td>Disease duration (median (IQR)), years</td><td>18 (15–28)</td><td>9 (4–15)</td><td>0.005</td></tr><tr><td>Prior IBD-related abdominal surgery, %</td><td>60</td><td>37</td><td>NS</td></tr><tr><td>Tobacco use, %</td><td>0</td><td>17</td><td>NS</td></tr><tr><td>Joint inflammation, %</td><td>27</td><td>6</td><td>0.01</td></tr><tr><td>CRP level (median (IQR)), mg/L</td><td>4.8 (1.1–11.8)</td><td>2 (0.6–5.6)</td><td>NS</td></tr><tr><td>Serum albumin level (median (IQR)), g/L</td><td>41 (39–43)</td><td>41 (39–43)</td><td>NS</td></tr><tr><td>Vitamin D level (median (IQR)), nmol/L</td><td>55 (35–62)</td><td>43 (34–66)</td><td>NS</td></tr><tr><td>Fecal calprotectin level (median (IQR)), µg/g</td><td>47 (28–1100)</td><td>50 (14–265)</td><td>NS</td></tr><tr><td>Crohn's disease, %</td><td>80</td><td>49</td><td>NS</td></tr><tr><td>Ulcerative colitis, %</td><td>17</td><td>52</td><td>NS</td></tr><tr><td><strong>IBD activity at month 6, %</strong></td><td></td><td></td><td></td></tr><tr><td>Remission</td><td>67</td><td>74</td><td>NS</td></tr><tr><td>Need for surgery</td><td>0</td><td>11</td><td>NS</td></tr><tr><td>Hospitalization</td><td>0</td><td>13</td><td>NS</td></tr><tr><td>Therapeutic change</td><td>33</td><td>15</td><td>NS</td></tr></tbody></table>

Values are presented as percentages unless specified otherwise. CRP: C-reactive protein. IBD: inflammatory bowel disease. BMI: body mass index.

Sarcopenia specifically in IBD patients [9]. Due to the particularly heterogeneous diagnostic criteria from one study to another, comparing results is challenging. Specifically, the muscle mass loss is often assessed using imaging techniques that measure the muscle surface area. Finally, several studies are based solely on the assessment of the muscle mass by cross-sectional imaging, which strictly speaking corresponds to an assessment of myopenia and not of sarcopenia. Therefore, our criteria were more rigorous but more restrictive.

Few recent studies have reported the prevalence of sarcopenia in IBD using the EWGSOP criteria, which combine assessments of muscle strength and mass. The results are summarized in Table 4. Bryant et al. [7] measured sarcopenia prevalence at 12 % with handgrip test and DEXA in patients mostly in clinical remission, which is in line with our results. Sarcopenia is more prevalent in inpatient patient, estimated at 21.9 % by Neelam et al. [10]. On the other hand, in the recent Turkish study in 129 outpatients with IBD [6], the authors have found a sarcopenia prevalence of only 2 % and a probable sarcopenia prevalence of 35 %. Notably, patients in this study were less frequently treated with biologics (40 %) and had more often received corticosteroids in the past year. Furthermore, corticosteroid use was specifically associated with an

increased risk of probable sarcopenia. These results are therefore difficult to compare with those we obtained in populations with easier access to advanced therapies.

In summary, our study has several distinctive features compared to previously published articles. Notably, our study population consists exclusively of ambulatory patients, unlike those in existing studies. Additionally, the definition of sarcopenia in our study incorporates both morphological and functional criteria, in line with the latest recommendations.

Although CD and UC are both classified as IBD, their characteristics are distinct. Consequently, malnutrition plays a more significant role in the pathogenesis of sarcopenia in patients with CD than in those with UC. Sarcopenia is particularly common in CD patients, especially those who require surgery. A retrospective study has shown that UC patients had significantly higher skeletal muscle area, SMI, visceral fat area, and subcutaneous fat area compared to those with CD [21]. The prevalence of sarcopenia was significantly lower in UC patients (27.3 %) than in those with CD (59.0 %), indicating that CD has a greater impact on the nutritional status and body composition than UC. In a 90-day prospective study in 110 IBD patients, improvements in symptoms, changes in treatment plans, and adverse outcomes (such as surgery, rehospitalization, and death) were observed [22]. These findings also indicated that CD patients had lower SMM values than UC patients. Additionally, reduced physical activity contributed to the muscle mass loss in CD patients, as even those in remission showed a decreased muscle mass [23]. Our study did not reveal any significant difference in the prevalence of sarcopenia between UC and CD patients, as described in the literature. This could be due to the limited statistical power of our study due to the relatively small size of our population. In clinical practice, it is important to remember that sarcopenia is not specific to CD patients, since it also occurs, although less frequently, in UC patients.

The fact that we did not assess our patients' physical activity is a limitation of this study, since it is well known that sarcopenia is associated with reduced activity and that physical activity is an effective measure to prevent sarcopenia [24]. An Italian observational study has shown that out of 200 IBD patients, 43 % were inactive and only 4 % reported significant physical activity [25]. A Korean study has also shown that even moderate physical activity was associated with a better quality of life [26]. Furthermore, the fact that we showed that the presence of joint inflammation was associated with a higher prevalence of sarcopenia could be explained by the resulting lower physical activity. A recent French study has shown a reduction in training frequency in 298 IBD patients, and that an increased physical activity correlated with a higher quality of life score [27]. This study has highlighted the fact that supporting patients to increase their physical activity was limited by a lack of training among practitioners.

<table><caption>**Table 4**
Studies reporting on prevalence of sarcopenia in IBD according to the EWGSOP recommendation (adapted from Neelam et al. 2024).</caption><thead><tr><th>No</th><th>Author</th><th>Year</th><th>Country</th><th>Number of patients</th><th>Parameters measured</th><th>Prevalence</th><th>Comments</th></tr></thead><tbody><tr><td>1</td><td>Bryant et al</td><td>2015</td><td>Australia</td><td>137<br>CD: 95<br>UC: 42</td><td>Muscle strength: handgrip test<br>Muscle mass: DEXA</td><td>12 %</td><td>Mix of inpatient and outpatient<br>Active IBD in 54 % CD patients, in 64 % UC</td></tr><tr><td>2</td><td>Pizzoferrato et al</td><td>2019</td><td>Italy</td><td>127<br>CD: 69<br>UC: 58</td><td>Muscle strength: degree of<br>asthenia based on VAS 1–100<br>Muscle strength: handgrip test<br>Muscle mass: DEXA and BIA</td><td>28 %</td><td>Questionable criterion for assessing muscle strength: asthenia<br>Active IBD in 45 % patients, severe activity in 4 % of patients</td></tr><tr><td>3</td><td>Liu et al</td><td>2022</td><td>China</td><td>110<br>CD: 25<br>UC: 85</td><td>Muscle strength: handgrip test<br>Muscle mass: BIA</td><td>30 %</td><td>No description of IBD population</td></tr><tr><td>4</td><td>Neelam et al</td><td>2023</td><td>India</td><td>114 (UC)</td><td>Muscle strength: handgrip test<br>Muscle mass: DEXA</td><td>21.9 %</td><td>Mostly inpatient inclusion<br>Active IBD in 73 % of patients, severe activity in 31.6 % of patients</td></tr><tr><td>5</td><td>Ergenc et al</td><td>2024</td><td>Turkey</td><td>129<br>- CD: 63<br>- UC: 66</td><td>Muscle strength: handgrip test<br>Muscle mass: BIA</td><td>2 %</td><td>Outpatient in tertiary center<br>Disease activity in 27 % of CD and in 29 % UC patients (severe activity in 8 % of CD and in 4 % of UC patients)</td></tr></tbody></table>
We did not identify any factors associated with poor clinical outcomes. This could be due to the low initial clinical activity, the limited follow-up duration and, again, the insufficient statistical power due to the small sample size.

Interestingly, sarcopenic patients do not show signs of malnutrition when assessed using classical indicators such as the BMI, as previously demonstrated [9]. This observation underlines the need for specific diagnostic methods. Furthermore, our data showed that overweight did not exclude the diagnosis of sarcopenia in these patients. Adams et al. had already described this, also showing that sarcopenia in these patients was a predictor of subsequent surgery [28].

The interest of our study was to demonstrate that, even in this specific population with low disease activity, more than one patient in ten developed sarcopenia. This finding was based on a rigorous diagnosis using simple tests combining muscle function (dynamometer) and muscle mass (BIA) assessments.

The simplicity of the tests used contrasts with other methods for assessing the muscle mass or function. The gold standard for muscle mass assessment remains DXA [29], but DXA equipment is not portable and is not suitable for widespread use in community settings [7,10]. In contrast, the device used for BIA is a low-cost, widely available, single-frequency portable device that can be easily used iteratively [6, 10]. It can be adapted using the muscle mass measurements of specific populations, determined by DXA, as a reference. Cross-sectional imaging techniques are more complex and cannot be performed at close intervals. Image analysis requires image processing software, which is not always available, dedicated analysis time for the radiologist, and in the case of CT-scans, the exposure of patients to radiation.

A practical approach to optimizing resources for sarcopenia screening could be to systematically measure the muscle strength by handgrip dynamometry during the day hospital stay, and to supplement this with BIA if probable sarcopenia is diagnosed.

However, to generalize the assessment of sarcopenia in IBD patients, new non-invasive diagnostic methods that can be integrated into daily practice are needed, ideally without the need for additional tests apart from routine care. The growing use of abdominal ultrasound to assess mucosal inflammation offers a promising opportunity to assess the muscle mass during the same examination. Recent study showed that muscle ultrasound a good accuracy in detecting sarcopenia compared to BIA [30]. If, ultrasound criteria for assessing the muscle mass have not yet been clearly defined, we can hypothesize a possible future place especially in IBD patients [31]. Intestinal ultrasound is emerging as a non invasive tool for monitoring disease activity in IBD, so the muscle assessment during ultrasound routine monitoring could become a new essential tool in the nutritional status evaluation. The use of artificial intelligence for processing cross-sectional imaging, preferably non-irradiating methods such as MRI, is also very promising in the near future [32,33]. Finally, regardless of the muscle mass assessment method used, it is essential to define sarcopenia criteria adapted to a younger population, given that IBD predominantly affects younger individuals.

## Conclusion

In a prospective study in an ambulatory IBD population, sarcopenia was identified in 10 % of patients using BIA measurements and handgrip strength tests. Screening for sarcopenia is therefore crucial in this population, including in stable outpatients in remission who do not meet malnutrition criteria and in overweight patients, as sarcopenia is associated with poorer clinical outcomes and increased postoperative complications. Interventional studies are needed to assess the impact of multidisciplinary treatment of sarcopenia on the quality of life and disease progression.

## Funding

This manuscript has not been funded.

## Writing assistance

Sophie Pégorier.

## CRediT authorship contribution statement

**Solène Dermine:** Writing – original draft, Validation, Supervision, Resources, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. **Thomas Bazin:** Writing – review & editing, Validation, Supervision, Software, Formal analysis. **Fatimé Adam Hassan:** Funding acquisition, Data curation. **Johanna Bettolo:** Investigation. **Lore Billiauws:** Investigation, Conceptualization. **Justine Bourdille:** Investigation. **Clément Bresteau:** Investigation. **Olivier Corcos:** Investigation. **Myriam El khatib:** Investigation. **Ashiq Mohamed Gouse:** Investigation, Funding acquisition. **Coralie Hutinet:** Investigation. **Alexandre Nuzzo:** Writing – review & editing, Validation, Software, Methodology, Conceptualization. **Francisca Joly:** Writing – review & editing, Visualization, Validation, Supervision, Project administration, Methodology, Conceptualization.

## Declaration of competing interest

The authors of this manuscript have no conflicts of interest to disclose as described by Clinics and Research in Hepatology and Gastroenterology.

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