Diagnostic criteria for sarcopenia (EWGSOP2, AWGS2, SDOC) and their prognostic value: a systematic review and meta-analysis of prevalence, all-cause mortality, and hospitalisation

Abstract

Three current consensus definitions for sarcopenia—EWGSOP2 (2019), AWGS2 (2019), and SDOC (2020)—differ substantially in their conceptual framework and operational cutoffs. No published meta-analysis has quantitatively pooled prognostic estimates across all three criteria. We aimed to compare pooled prevalence and prognostic associations with all-cause mortality and hospitalisation across these three definitions. We conducted a PRISMA 2020-compliant systematic review with searches in PubMed, Embase, Cochrane CENTRAL, Web of Science, CNKI, and Wanfang from 1 January 2019 to 31 May 2026. Eligible studies enrolled adults in any setting (Population), applied EWGSOP2, AWGS2, or SDOC exactly as published (Index/Comparator constructs), and reported sarcopenia prevalence or adjusted associations with all-cause mortality or hospitalisation (Outcomes). Risk of bias was assessed with the JBI checklist (prevalence studies) and ROBINS-E (cohort studies). Random-effects meta-analysis used Freeman–Tukey transformation for prevalence and generic inverse variance with Hartung–Knapp adjustment for hazard ratios; subgroup, meta-regression, within-cohort indirect comparison, leave-one-out, and Egger publication-bias analyses were pre-specified, whereas meta-regression was exploratory. Pooled prevalence was 11.3% (95% CI 7.9–15.2; k = 37) for EWGSOP2, 23.2% (19.0–27.5; k = 31) for AWGS2, and 7.6% (3.1–13.9; k = 12) for SDOC. Pooled adjusted mortality HRs were 1.68 (95% CI 1.59–1.77; I²=0%; k = 19) for EWGSOP2, 1.97 (1.85–2.09; I²=0%; k = 14) for AWGS2, and 2.44 (2.21–2.71; I²=43%; k = 10) for SDOC. Pooled hospitalisation HRs were 1.58 (1.41–1.76; EWGSOP2), 1.71 (1.60–1.82; AWGS2), and 1.45 (1.38–1.53; SDOC). Asian populations showed substantially higher AWGS2 prevalence (24.4%) than European (7.8%). Egger tests indicated small-study effects for prevalence ( p < 0.001) and funnel asymmetry for AWGS2 mortality ( p = 0.018), although trim-and-fill did not alter any pooled estimate.In within-cohort comparisons of criteria applied to the same participants (k = 12 studies; N = 13,718), AWGS2 identified more cases than EWGSOP2 (OR 2.74, 95% CI 1.96–3.83, computed from marginal classifications).Sixty-two studies (90,161 participants) were included. The three sarcopenia criteria yield divergent prevalence estimates but converge in showing clinically meaningful associations with mortality. SDOC identified the smallest subgroup and showed the highest pooled mortality HR among the separately synthesised evidence pools; AWGS2 yielded the highest case identification together with a robust prognostic association in Asian populations; EWGSOP2 provided intermediate prevalence with a robust mortality association. These pooled HRs derive from different sets of studies and should not be read as a direct comparison of prognostic performance. Because the definitions capture partially overlapping but distinct constructs—and because the proportion of individuals classified as sarcopenic depends materially on the criterion chosen—criterion selection may influence clinical case identification and risk stratification and should be guided by local population characteristics and the clinical question rather than by any claim of overall superiority.