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Aging & Longevity

Sarcopenia and TCM

Skye Sturgeon, DAOM |

by Skye Sturgeon, DAOM

The age-related progressive loss of muscle mass and strength, known by its biomedical name as sarcopenia, is a type of muscle atrophy primarily caused by the natural aging process, although sarcopenia may be a feature of several disease processes. In this article, the symptoms, causes, risk factors, and treatment options will be explored, which will include recommendations from traditional Chinese medicine that can support the maintenance of normal muscle mass.  

aging man bent over with cane

Equally affecting both sexes and all ethnicities, sarcopenia gradually begins in one’s 30s and 40s and is found in approximately 10% of people aged 60 and older, increasing to as much as 50% of people older than 80. Rates vary but most people lose around 8% of their muscle mass each decade. Changes in hormone production, for example, testosterone and insulin-like growth factor (IGF-1), can adversely affect muscle cells and fibers, resulting in sarcopenia.

Symptoms 

The main symptom of sarcopenia is increasing muscle weakness. Other things to look out for include: 

  • Loss of stamina and the need for frequent rests  
  • Difficulty performing daily activities  
  • Walking slowly 
  • Difficulty walking while carrying weight 
  • Trouble climbing stairs 
  • Poor balance and falls 
  • Decrease in muscle size, i.e., noticeable shrinkage of muscles, e.g., biceps, gastrocnemius, pectoral, et al.  

Factors that Increase the Risk of Developing Sarcopenia 

  • Aging 
  • Physical inactivity; a sedentary lifestyle 
  • Obesity. i.e., a BMI >30. Fat infiltration into skeletal muscle lowers muscle quality and accelerates loss of lean body mass 
  • Chronic diseases such as chronic obstructive pulmonary disease (COPD), kidney disease, diabetes, cancer, heart disease, HIV, et al. 
  • Rheumatoid arthritis (not osteoarthritis, although it can contribute to diminished physical activity) 
  • Insulin resistance (prediabetes or diabetes: glucose struggles to enter muscle cells starving them of energy; IR may also cause hyperglycemia, i.e. high sugar in the blood- see below) 
  • Reduction in hormone levels, especially Growth Hormone, IGF-I, testosterone, and to a lesser extent, glucocorticoids and thyroid hormones 
  • Malnutrition or inadequate protein intake, especially a lack of essential amino acids 
  • Decrease in the ability to convert protein to energy (gluconeogenesis is the breakdown of amino acids to create glucose, which is the energy source necessary for cellular metabolism) 
  • Poor dietary choices such as ultra processed food  
  • Contracting diseases that increase systemic inflammation, e.g. viruses, et al. 
  • Decline in the number or function of nerve cells that send messages from the brain to muscles to initiate movement 

Diabetes and Sarcopenia 

Diabetes mellitus patients have a higher prevalence of sarcopenia. Diabetes aggravates the metabolic disturbance, including the symptoms mentioned above, and the treatment of diabetes using anti-diabetic drugs has been shown to have a differential effect on skeletal muscle mass, strength, and performance. Untreated diabetes causes hyperglycemia with the development of various pathologies including micro and macrovascular complications, oxidative stress, the creation of advanced glycation end products (AGEs), and increasing insulin resistance. All of these can damage muscle cells and tissues. Poor glycemic control in patients with diabetes could exacerbate and lead to lower muscle mass.  

There is a plethora of antidiabetic drugs with Insulin secretagogues such as glinides (e.g., Prandin) and sulphonylureas (e.g., Glipizide) having been demonstrated to have a deleterious on maintaining muscle mass, while metformin, sodium‐glucose co‐transporter 2 (SGLT2) inhibitors (e.g., gliflozin / Jardiance®), and thiazolidinediones (e.g., Avandia® and Actos®) have mixed and sometimes controversial effects. 

Biosynthetic human insulin (e.g., NovoLog® /insulin aspart) and Lantus®/ insulin glargine). dipeptidyl peptidase IV (DPP‐IV) inhibitors (e.g., Januvia® / sitagliptin) and glucagon‐like peptide‐1 (GLP‐1) agonists (e.g., Ozempic®, Wegovy®) generally have an enhancing effect on muscle mass. There have been recent reports in the media about muscle loss associated with GLP-1 agonists, but this is believed to be an effect associated with the reported overall weight loss, since GLP-1 agonists suppress the appetite and reduced caloric intake results in weight loss that does not discriminate between fat and muscle.  

diagram showing muscle loss

Criteria indicating a Diagnosis of Sarcopenia 

These assessments can be repeated over time to evaluate improvement or deterioration. During a physical exam and medical history questioning, assess the following: 

  • Hand grip strength (Use a dynamometer or have patient squeeze your fingers) 
  • Can a patient lift a ten-pound weight? Twenty pounds? (A barbell or kettle bell will prove useful.) 
  • Can they carry the weight around without losing their balance or needing to stop and rest? 
  • Can a patient walk across a room without a cane, walker, or other assistance (e.g., touching furniture or the wall)? How fast can they walk a measured distance? Can they turn sharply without losing their balance? 
  • Can they easily rise from a chair without using their arms for assistance? 
  • Are they able to walk up and down stairs without using their arms for assistance (or losing their balance)? Can they walk up and down stairs while carrying a weight? 
  • Using a measuring tape, determine the size of the biceps and/or gastrocnemius to evaluate and track changes in musculature. 

Mitigating the Effects of Sarcopenia Associated with Aging 

Since sarcopenia increases as one ages, the recommended strategy is to slow down this inevitable progression.  Much of this advice is applicable to combating nearly every health challenge a person encounters as they age.  

Maintain a healthy diet

Even though one’s caloric needs diminish somewhat as they age, to avoid muscle mass loss, a healthy diet must include high-quality proteins, since protein is the main component of muscles. (Vegetarians must ensure that they are getting all eight essential amino acids.) Twenty to thirty-five grams of protein in each meal is recommended. For example, a four-ounce serving of chicken or fish contains ~28g, two eggs provide 12g, a half cup of beans has 6-9g, and 8 oz. of milk provides about 8 g. Grains and vegetables contain some protein, but significantly less, in the range of 2-3g per serving. 

Exercise

Exercise challenges the body to maintain and create new muscle fibers. This is a case of ‘use it or lose it’. As one ages, it becomes more difficult to engage in athletics, largely due to sarcopenia. If one spends a lot of time in a chair or in bed, muscle loss increases dramatically. Low impact physical activity such as cycling or walking is very helpful. Swimming is cardiovascularly beneficial but does not maintain muscle mass as well. Many studies have demonstrated the importance of resistance and strength training in maintaining muscle mass.  This does not mean that one must ‘hit the gym’ or buy equipment for a home gym, although dumbbells and barbells can replace more sophisticated equipment. Resistance bands can be used for strength training and improving flexibility, balance, and mobility. They are versatile, lightweight, and can be used for a variety of exercises targeting different muscle groups. In addition, bodyweight exercises are workouts that use your own body weight as resistance. They can be done anywhere and are suitable for all fitness levels, such as push-ups, squats, burpees, and abdominal floor work such as planks and crunches 

Routine medical exams

Be sure to visit a healthcare provider regularly and have them monitor muscle mass along with any other health concerns.  

Traditional Chinese Medicine 

Traditional Chinese medicine (TCM) provides several approaches to slow down age-related muscle atrophy. Research has focused on three principal modalities of Chinese medicine. 

Traditional Chinese exercise (TCE) 

TCE enhances the recruitment of motor neurons to muscles, promotes the synthesis of mitochondrial related proteins, and thickens muscle fibers. Four forms of TCE have been extensively studied and these are Tai Ji Quan 太極拳, Yi Jin Jing Qi Gong 易筋經氣功 (Muscle Tendon Changing Exercises), Ba Duan Jin Qi Gong 八段錦氣功(Eight Pieces of Brocade), and Wu Qin Xi Qi Gong 五禽戲氣功 (Five Animal Frolics). Although each has a different focus, all these exercise regimes foster endurance, resistance, balance, and flexibility, and include breath practices and meditation.  Among the findings, these exercises activate crucial signaling pathways in skeletal muscle, increased mitochondria activity, thickened muscle fibers, increased muscle strength measures, and slowed skeletal muscle atrophy. It is important to note that while research has indicated that the practice of these exercises significantly increased walking times and lower limb strength and muscle mass, there was no notable impact on grip strength and upper body muscle mass.  

Acupuncture 

Generally, acupuncture has not been shown to relieve symptoms in patients with sarcopenia. However, acupuncture can play an important adjunctive role since it may help regulate inflammatory cytokines and muscle-specific enzymes that play a key role in muscle atrophy. For example, electroacupuncture using ST36 and SP9 of rats with diabetes-induced muscular atrophy has been shown to reduce the expression of MURF-1 (an enzyme important in muscle remodeling), to prevent the degradation of the myosin motor proteins, and to delay the process of muscular atrophy. In addition, acupuncture can promote autophagy which is a process of the immune system that can remove damaged proteins and provide materials for protein self-renewal that inhibits apoptosis (cell death) of skeletal muscle cells. It has also been reported that electroacupuncture at ST36 and GB30 can promote autophagy to improve gastrocnemius atrophy in rats with dystrophic muscular atrophy. Among the acupoints that have been the subject of inquiry regarding sarcopenia are San Yin Jiao (SP6), Tai Bai (SP3), Yin Ling Quan (SP9), Su San Li (ST36), Yang Ling Quan (GB34), Qu Quan (LV8), Tai Xi (KI3), and Zhi Gou (SJ6). 

Chinese Herbs 

In Chinese medicine theory, the Spleen controls the muscles. The Spleen extracts the Qi from food to nourish all the tissues in the body and transports this refined Qi via the Channels and Blood.  If the Spleen is strong, the muscles will be strong, particularly those of the limbs. To keep the Spleen and muscles strong, the Liver must be in harmony to optimize its control of the Spleen and Stomach. A proper diet and adequate rest are necessary for the Spleen to function correctly. Otherwise, tonification of the Spleen and Stomach Qi, and to a lesser degree the Blood, is indicated to support nutrition of the entire body, including the muscles. 

Ba Zhen Tang/ Eight Treasures Decoction and Bu Zhong Yi Qi Tang/ Tonify the Middle and Augment the Qi Decoction are the most studied Chinese herbal formulas to benefit Qi and strengthen the function of Spleen and Stomach to reduce muscle weakness. Interestingly, these formulas were studied as supplementation and not necessarily based on TCM diagnostic criteria.  For example, Ba Zhen Tang was recommended for post-menopausal females to stave off sarcopenia and who did not show the obligatory signs and symptoms required to demonstrate Qi and Blood Deficiency. 

Both these Chinese herbal therapies decreased reactive oxygen species (ROS) that can cause damage to mitochondria in skeletal muscle cells. Additionally, research results indicated that herbal medicine has a beneficial effect on improving muscle strength and physical function in patients based on exercise and nutritional supplementation.  

In addition to its TCM indications (see charts), Bu Zhong Yi Qi decoction was able to reduce inflammatory factors in patients. Animal studies have shown that Huang Qi/ Astragalus membranaceus root, which is contained in Bu Zhong Yi Qi Tang, has antioxidant and anti-aging effects. Astragalus polysaccharides have been shown to significantly increase the activities of key antioxidant enzymes that protect cells from damage from ROS including catalase (CAT), superoxide dismutase (SOD), and glutathione peroxidase (GPx), as well as anti-hydroxyl radicals in aging mice.  Both Ba Zhen Tang and Bu Zhong Yi Qi Tang contain Bai Zhu/ Atractylodes macrocephala root and Chuan Xiong/ Ligusticum chuanxiong rhizome. In studies, Bai Zhu was shown to increase SOD activity, scavenge reactive oxygen radicals, and reduce malondialdehyde content in the erythrocytes of mice over 12 months of age. (Malondialdehyde (MDA) is a naturally occurring compound that serves as a marker of oxidative stress and lipid peroxidation.) In aging rats, the SOD content in the serum and rectus femoris muscle was increased by administering Bai zhu and Huang qi, thus reducing oxidative damage and delaying the aging of skeletal muscles. Chuan xiong contains tetramethylpyrazine (TMP), which can improve age-related musculoskeletal disorders in humans and prolong their lifespan.  

Other formulas that have been subjects of sarcopenia research include Si Jun Zi Tang/Four Gentlemen and Shen Ling Bai Zhu Tang. Other herbs were included as modifications in some of these formulas. Specific rationales were not provided, and one can speculate why some researchers included these herbs.  Among those commonly included were:  

  • Pseudostellaria heterophylla root/ Tai zi shen, Strengthens the Spleen and tonifies Qi 
  • Tortoise plastron/ Gui ban, Nourishes the Blood and enriches Yin 
  • Cervus elaphus antler gelatin (degelatinized) / Lu jiao shuang, Augments Essence and Blood 
  • Schisandra chinensis fruit/ Wu wei zi, Tonifies Qi 
  • Codonopsis pilosula root/ Dang Shen, Tonifies Qi. Dang shen is commonly used as a substitute for Panax ginseng root/Ren shen. 

Ba Zhen Tang
PHARMACEUTICAL
PIN YIN
DOSAGE
ACTIONS
Radix Ginseng
 Ren Shen
 3-9g Tonifies Qi and strengthens the Spleen and Stomach.
(Radix Codonopsis) (Dang shen) 6-27g (A substitute for Ren shen.)
Rhizoma Atractylodis Macrocephalae Bai zhu
 3-12g Tonifies the Spleen, augments Qi and dries Dampness.
Poria Cocos Fu ling 3-15g Dries Dampness and strengthens the Spleen.
Radix Glycyrrhizae Preparata Zhi Gan cao 1.5-6g Augments Qi, warms and strengthens the Middle Jiao and moderates and harmonizes the harsh properties of other herbs.
Radi. Rehmanniae Preparata
 Shu Di huang
 3-18g Strengthens the Liver and Kidneys, and nourishes the Yin of the Blood.
Radix Paeoniae Alba Bai shao 3-15g Tonifies Blood and preserves Yin.
Radix Angelicae Sinensis Dang gui 3-15g Tonifies and invigorates the Blood, moistens the Intestines and regulates the relationship between the Liver and Kidneys.
Rhizoma Chuanxiong   Chuan xiong 3-9g Invigorates the Blood, activates Qi, releases constraint, and alleviates pain.
Rhizoma Zingiberis Recens
 Sheng jiang 1-3g Regulates the Spleen and Stomach.
Fructus Jujube Da zao 1.5-5g Tonifies the Spleen and Stomach, augments Qi, nourishes the Blood, calms the Spirit and moderates and harmonizes the harsh properties of other herbs.

Bu Zhong Yi Qi Tang
PHARMACEUTICAL
PIN YIN
DOSAGE
ACTIONS
Radix Astragali
 Huang qi
 3-30g Strongly tonifies Qi, strengthens the Spleen and raises Spleen Yang.
Radix Ginseng
 Ren Shen
 3-20g Tonifies Qi and strengthens the Spleen and Stomach. 
(Radix Codonopsis) (Dang shen)  8-30g (A substitute for Ren shen.)
Rhizoma Atractylodis Macrocephalae Bai zhu
 3-12g Strengthens the Spleen and dries Dampness.
Honey-Fried Radix Glycyrrhizae Zhi Gan cao 3-15g Tonifies the Spleen and harmonizes.
Radix Angelicae Sinensis 
 Dang gui 3-12g Tonifies the Qi of the Blood and invigorates and harmonizes the Blood.
Pericarp Citri Reticulatae Chen pi 3-12g Regulates Qi, tonifies the Spleen, assists in raising Qi.
Radix Cimicifugae Sheng ma 3-10g Raises Yang, raises sunken Qi and guides other herbs upwards.
Radix Bupleurum Chai hu 3-9g Raises Yang Qi and relieves Stagnation.
Rhizoma Zingiberis Recens Sheng jiang
 3-6g Harmonizes and protects the Spleen and Stomach.
Fructus Jujube Da zao 3-6g Harmonizes and protects the Spleen and Stomach.

When encountering aging patients that exhibit signs and symptoms of sarcopenia, the TCM practitioner has several modalities they can use to support their patient’s condition. By emphasizing the standard treatments of a diet that includes high quality protein and exercise that includes resistance and weight training, the acupuncturist can then add traditional Chinese exercises, acupuncture, and Chinese herbs to their regimen, which will provide a complete, integrated program that can be expected to improve the patient’s condition and their quality of life. 

References 

About the Author

Skye Sturgeon, DAOM is the Quality Assurance Manager and Special Consultant for Mayway, USA. Skye was the former Chair of Acupuncture & East Asian Medicine and core faculty member at Bastyr University, core faculty member and Faculty Council Chair at the American College of Traditional Chinese Medicine, and President and Senior Professor of the Acupuncture & Integrative Medicine College, Berkeley. Before making Chinese medicine his career choice, Skye held various positions in the Natural Foods Industry for 12 years and prior to that was a clinical biochemist and toxicologist.

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