a clinical need exists to optimally identify those who will sustain fragility fractures . simply utilizing bone mineral density ( bmd ) measurement alone is not adequate , as the majority of people who sustain osteoporosis - related fractures do not have osteoporosis by bmd t - score [ 14 ] . as such , major efforts to improve fracture risk estimation continue , e.g. , development of calculators such as frax , garvan and qfracture that include clinical risk factors [ 511 ] . however , using existing calculators some people at low estimated risk sustain fractures and not all at high risk do fracture . this increase is much greater than the corresponding bmd decline [ 14 , 15 ] . as such ,  age encompasses factors that increase fracture risk , including , among others , declining functional status and increased falls risk . sarcopenia , the age - related decline in muscle mass and function , is associated with increased risk for falls , frailty and fractures [ 1624 ] and may well explain some / much of the increased risk currently attributed to  age . consistent with this , in the dubbo study age was not associated with fracture risk after correction for muscle strength and body sway [ 25 , 26 ] . it is possible that individuals with both osteoporosis and sarcopenia (  sarco - osteoporosis  ) are at greatest fracture risk [ 2730 ] . indeed , a recent report of over 300 women with hip fracture found 45  % to have both osteoporosis and sarcopenia . therefore , evaluation of sarco - osteoporosis as a fracture risk factor , and assessment of approaches to improve this diagnosis , is appropriate . current consensus sarcopenia definitions include appendicular lean mass ( alm ) adjusted for height ( alm / ht ) [ 20 , 22 , 32 ] . however , height loss is common with advancing age and confounds body mass index ( bmi ) and body composition assessment in older adults [ 33 , 34 ] . as many older adults are shorter than their tallest height , their alm / ht value is higher than if no height loss had occurred thereby making them less likely to be classified as sarcopenic . moreover , differing amounts of height loss between individuals will introduce unappreciated variability into any clinical cut point alm / ht ratio selected to include in the definition of sarcopenia . recognizing this potential confounder , some prior sarcopenia studies have adjusted for height loss [ 34 , 35 ] . however , to our knowledge , the effect of using tallest reported rather than current height on sarcopenia prevalence has not been reported . however , spine bmd as measured by dual - energy x - ray absorptiometry ( dxa ) is commonly elevated in older adults by degenerative changes [ 3638 ] . proximal femur measurements , while less frequently affected , are not immune to the impact of degenerative changes . in contrast , bmd measurement at the one - third radius is unaffected by degenerative changes . prior work finds radius bmd measurement to be important in older adults , and documents the ability of this site to predict fracture risk . thus , it is possible that routine performance of one - third radius bmd measurement in older adults might improve fracture risk prediction . the overarching purpose of this work is to suggest potential approaches that are easily applicable that may enhance fracture prediction and to begin their evaluation . to this end , we hypothesized that use of historical tallest height in the alm / ht ratio and inclusion of radius bmd t - score might enhance identification of sarcopenia and osteoporosis , respectively , thereby facilitating sarco - osteoporosis recognition and potentially fracture risk estimation in older adults . to test this hypothesis , the aims of this study in a group of adults age 60 + years were to : ( 1 ) evaluate the effect of inclusion of one - third radius bmd measurement on t - score distribution and use of historical height vs. current height on the alm / ht ratio and ( 2 ) define the prevalence of sarcopenia , osteoporosis and sarco - osteoporosis with and without using one - third radius bmd and historical height . here we report the effect of these approaches on prevalence of osteoporosis , sarcopenia and sarco - osteoporosis in a convenience sample of 304 community dwelling adults age 60  years and over . data from three studies performed at the university of wisconsin osteoporosis clinical research program were included in this analysis . these studies include the midus ( mid - life in the united states ) ii study ,  precision ,  a dxa precision research study comparing bmd and body composition between two ge healthcare lunar densitometers , ( idxa and prodigy ) and  jump ,  a study examining jump mechanography as a tool to assess function in older adults . participants from the midus biomarker project study ( n  =  44 ) ,  precision ( n  =  164 ) and  jump  ( n  =  96 ) comprise a sample of older community dwelling adults , primarily from the madison , wi area . all studies were reviewed and approved by the university of wisconsin health sciences irb and all participants signed an informed consent document prior to conduct of any study procedure . a ge healthcare lunar ( madison , wi ) prodigy or idxa densitometer was used for all bmd and body composition measurements . excellent bmd and body composition assessment agreement is observed between the two densitometers used for this study . routine densitometry quality assurance procedures were followed ; no instrument drift or shift was detected during these studies . scans of the lumbar spine , proximal femur , non - dominant radius and total body were performed in routine clinical manner by international society for clinical densitometry ( iscd ) certified technologists . the lowest bmd t - score of the lumbar spine , femoral neck , total proximal femur or one - third radius was chosen to define osteoporosis using the world health organization ( who ) t - score based classification system . the lowest t - score at any of the above sites was used to classify each individual s skeletal status as recommended by the iscd . alm includes only lean mass , excluding fat and bone mass , of the arms and legs as depicted in fig .  1 . height for this ratio was based either on stadiometer - measured height performed on the day of dxa scanning or by participant self - reported tallest historical height . commonly utilized definitions of osteoporosis and sarcopenia were applied , i.e. , a t - score 2.5 at the lumbar spine or hip   and alm / current height < 5.45  kg / m ( female ) and < 7.26  kg / m ( male ) . for the  sensitive  definitions , a one - third radius t - score ( derived using the ge normative gender matched database ) of 2.5 was considered osteoporosis and the alm / ht ratio utilized historical tallest height and the sarcopenia cut points noted above of 5.45 and 7.26  kg / m were applied.fig . examples of the bone ( left ) and soft tissue ( right ) dxa image of an individual . appendicular lean mass ( alm ) is defined as the lean mass , excluding bone and fat , in the arms ( light gray region ) and legs ( dark gray region ) appendicular lean mass regions of interest . examples of the bone ( left ) and soft tissue ( right ) dxa image of an individual . appendicular lean mass ( alm ) is defined as the lean mass , excluding bone and fat , in the arms ( light gray region ) and legs ( dark gray region ) the potential importance of using a dxa site not affected by degenerative change was explored by defining the prevalence of obvious degenerative disease . to this end , all dxa spine images were reviewed by one experienced densitometrist ( nb ) . degenerative changes were considered to be present if obvious osteophytes , vertebral fractures , or focal degenerative changes involving less than an entire vertebral body , or a 1 t - score discrepancy between vertebral bodies was observed . demographic comparisons and evaluation of t - score comparability were performed using t - tests with statview ( cary , nc ) software . pearson and fisher chi - square statistics ( analyze - it ; leeds uk ) were used to compare the prevalence of osteoporosis , sarcopenia and sarco - osteoporosis using  standard  or  sensitive  definitions in the three age groups ( 6069 , 7079 and 80 + years ) . data from three studies performed at the university of wisconsin osteoporosis clinical research program were included in this analysis . these studies include the midus ( mid - life in the united states ) ii study ,  precision ,  a dxa precision research study comparing bmd and body composition between two ge healthcare lunar densitometers , ( idxa and prodigy ) and  jump ,  a study examining jump mechanography as a tool to assess function in older adults . participants from the midus biomarker project study ( n  =  44 ) ,  precision ( n  =  164 ) and  jump  ( n  =  96 ) comprise a sample of older community dwelling adults , primarily from the madison , wi area . all studies were reviewed and approved by the university of wisconsin health sciences irb and all participants signed an informed consent document prior to conduct of any study procedure . a ge healthcare lunar ( madison , wi ) prodigy or idxa densitometer was used for all bmd and body composition measurements . excellent bmd and body composition assessment agreement is observed between the two densitometers used for this study . routine densitometry quality assurance procedures were followed ; no instrument drift or shift was detected during these studies . scans of the lumbar spine , proximal femur , non - dominant radius and total body were performed in routine clinical manner by international society for clinical densitometry ( iscd ) certified technologists . the lowest bmd t - score of the lumbar spine , femoral neck , total proximal femur or one - third radius was chosen to define osteoporosis using the world health organization ( who ) t - score based classification system . the lowest t - score at any of the above sites was used to classify each individual s skeletal status as recommended by the iscd . alm includes only lean mass , excluding fat and bone mass , of the arms and legs as depicted in fig .  1 . height for this ratio was based either on stadiometer - measured height performed on the day of dxa scanning or by participant self - reported tallest historical height . commonly utilized definitions of osteoporosis and sarcopenia were applied , i.e. , a t - score 2.5 at the lumbar spine or hip   and alm / current height < 5.45  kg / m ( female ) and < 7.26  kg / m ( male ) . for the sensitive  definitions , a one - third radius t - score ( derived using the ge normative gender matched database ) of 2.5 was considered osteoporosis and the alm / ht ratio utilized historical tallest height and the sarcopenia cut points noted above of 5.45 and 7.26 examples of the bone ( left ) and soft tissue ( right ) dxa image of an individual . appendicular lean mass ( alm ) is defined as the lean mass , excluding bone and fat , in the arms ( light gray region ) and legs ( dark gray region ) appendicular lean mass regions of interest . examples of the bone ( left ) and soft tissue ( right ) dxa image of an individual . appendicular lean mass ( alm ) is defined as the lean mass , excluding bone and fat , in the arms ( light gray region ) and legs ( dark gray region ) the potential importance of using a dxa site not affected by degenerative change was explored by defining the prevalence of obvious degenerative disease . to this end , all dxa spine images were reviewed by one experienced densitometrist ( nb ) . degenerative changes were considered to be present if obvious osteophytes , vertebral fractures , or focal degenerative changes involving less than an entire vertebral body , or a 1 t - score discrepancy between vertebral bodies was observed . demographic comparisons and evaluation of t - score comparability were performed using t - tests with statview ( cary , nc ) software . pearson and fisher chi - square statistics ( analyze - it ; leeds uk ) were used to compare the prevalence of osteoporosis , sarcopenia and sarco - osteoporosis using  standard  or  sensitive definitions in the three age groups ( 6069 , 7079 and 80 + years ) . a total of 304 individuals ( 158 females , 146 males ) age 60 and above were included in this cross - sectional analysis . their age and bmi ( mean , sd and range ) was 75.5 ( 7.5 ) years ( 6095 ) and 27.1 ( 4.9 ) kg / m ( 15.151.6 ) , respectively . the male cohort was slightly ( p  <  0.05 ) older . as could be expected , the males were taller and heavier ( p  <  0.001 ) than the females ; however , mean bmi did not differ . bmd t - score was lower ( p  <  0.05 ) at all sites in women . similarly , alm / ht was lower ( p  <  0.001 ) in women . participants were stratified by decade of age : 6069 ( n  =  89 ) ; 7079 ( n  =  119 ) ; and 80 + ( n  =  96).table 1study participant demographic dataage ( years)bmi ( kg / m)height loss ( cm)l1l4 t - scorefemoral neck t - scoretotal femur t - scoreone - third radius t - scorealm / height ( kg / m)female n  =  15874.5 * ( 7.0)27.1 ( 5.5)3.7 * ( 2.9)0.7 ( 1.7)1.5 * ( 0.9)1.0 * ( 1.1)1.9 ( 1.4)6.5 ( 1.0)male n  =  14676.5 ( 7.9)27.2 ( 4.0)4.5 ( 3.1)+0.9 ( 2.1)1.1 ( 1.0)0.7 ( 1.1)0.5 ( 1.1)8.1 ( 1.0)data are presented as mean ( sd)different than males : * p  <  0.05 ; p  < 0.001 study participant demographic data data are presented as mean ( sd ) different than males : * p  <  0.05 ; p  <  0.001 obvious degenerative changes ( examples in fig . 2 ) were apparent on the dxa image in virtually all ( 93  % ) of these volunteers . only 14 of 158 ( 9  % ) of the women and eight of 146 ( 5  % ) of these men had no apparent degenerative changes . as a result , lumbar spine t - scores deviated from normal to a lesser degree than in the radius in both men and women ( p  <  0.0001 ; fig .  3 ) . of those 14 individuals without obvious degenerative changes on their dxa image , 59  % were less than age 70.fig . examples of what were considered as  obvious  degenerative changes on the dxa images are presented here . the image on the left is a 70-year - old man in whom focal abnormalities at l2 and l3 are apparent . the individual vertebral body t - scores are consistent ; from l1 to l4 these values are + 1.1 , + 4.5 , + 4.2 and + 1.7 ; thus , a > 1 t - score difference is present between adjacent vertebrae . the 86-year - old female on the right has apparent degenerative changes at l2 , l3 and l4 with obvious osteophytes at l2 and l3 . t - score differences between adjacent vertebrae were observed with values from l1 through l4 being + 0.2 , + 1.7 , + 3.5 and + 4.1 , respectivelyfig . 3comparison of lumbar spine , femur neck and one - third radius t - scores in men and women . depicted are distribution curves ( using a normal continuous fit function ) of lumbar spine , femur neck and one - third radius t - scores in men ( a ) and women ( b ) . in both genders mean bmd t - scores were the higher at lumbar spine compared to the femur neck or the one - third radius site ( all p  <  0.0001 ) . mean bmd t - scores at the femur neck were higher than the one - third radius in females but lower in males ( all p  <  0.01 ; see table  1 for t - score values and their standard deviations ) . the broad range of lumbar spine t - scores in males is striking with values above + 5 in some men . this was not the case in the one - third radius site examples of spinal degenerative changes . examples of what were considered as  obvious  degenerative changes on the dxa images are presented here . the image on the left is a 70-year - old man in whom focal abnormalities at l2 and l3 are apparent . the individual vertebral body t - scores are consistent ; from l1 to l4 these values are + 1.1 , + 4.5 , + 4.2 and + 1.7 ; thus , a > 1 t - score difference is present between adjacent vertebrae . the 86-year - old female on the right has apparent degenerative changes at l2 , l3 and l4 with obvious osteophytes at l2 and l3 . t - score differences between adjacent vertebrae were observed with values from l1 through l4 being + 0.2 , + 1.7 , + 3.5 and + 4.1 , respectively comparison of lumbar spine , femur neck and one - third radius t - scores in men and women . depicted are distribution curves ( using a normal continuous fit function ) of lumbar spine , femur neck and one - third radius t - scores in men ( a ) and women ( b ) . in both genders mean bmd t - scores were the higher at lumbar spine compared to the femur neck or the one - third radius site ( all p  <  0.0001 ) . mean bmd t - scores at the femur neck were higher than the one - third radius in females but lower in males ( all p  <  0.01 ; see table  1 for t - score values and their standard deviations ) . the broad range of lumbar spine t - scores in males is striking with values above + 5 in some men . this was not the case in the one - third radius site self - reported tallest height was greater than current stadiometer - measured height in 97  % ( 296/304 ) of study participants . males had a larger mean reported height loss than females ( 4.5 vs. 3.7  cm ; p  <  0.05 ; table  1 ; fig .  4a ) . use of reported tallest height in the alm / ht ratio reduced this value by a mean of 4.9  % in men and 4.4  % in women ( fig . the distribution curves ( using a normal continuous fit function ) for the amount of reported historical height loss ( a ) shows a mean of 4.5  cm in men and 3.7  cm in women . the variability of height loss is striking with some individuals reporting more than 10  cm of height loss . the negative values ( suggesting height gain ) are evidence of limitations of historical tallest height . the distribution curves of percentage change of using reported historical height loss instead of current height show that in both genders the mean alm / height ratio was decreased ( 4.4  % in females and 4.9  % in males ) historical height change and effect on alm / ht ratio . the distribution curves ( using a normal continuous fit function ) for the amount of reported historical height loss ( a ) shows a mean of 4.5  cm in men and 3.7  cm in women . the variability of height loss is striking with some individuals reporting more than 10  cm of height loss . the negative values ( suggesting height gain ) are evidence of limitations of historical tallest height . the distribution curves of percentage change of using reported historical height loss instead of current height show that in both genders the mean alm / height ratio was decreased ( 4.4  % in females and 4.9  % in males ) the prevalence of sarcopenia increased with age ( p  <  0.01 ) using either the standard or  sensitive  criteria ( fig . the  sensitive  criteria identified more individuals with sarcopenia than the standard criteria ( p  <  0.0001 ) . overall , 15  % of this cohort was classified as sarcopenic with standard criteria whereas the sensitive criteria identified 26  % .fig . 5prevalence of sarcopenia , osteoporosis and sarco - osteoporosis by decade using standard or sensitive criteria . sarcopenia was more common in individuals age 80 + than 7079 and 6069  years ( p  <  0.01 ) regardless of criteria used ( a ) . significantly more ( p  <  0.0001 ) individuals had sarcopenia using the sensitive criteria ( alm / reported historical tallest height ) compared to standard criteria ( alm / current height ) . similarly , osteoporosis was more common in individuals age 80 + than 7079 and 6069 ( p  < 0.001 ) regardless of criteria used ( b ) . significantly more ( p  <  0.0001 ) individuals had osteoporosis using the sensitive criteria ( lowest t - score from hip , lumbar spine and one - third radius ) compared to standard criteria ( lowest t - score of hip and lumbar spine only ) . sarco - osteoporosis was more common in individuals age 80 + than 7079 and 6069 ( p  <  0.05 ) regardless of criteria used ( c ) . significantly more ( p  <  0.0001 ) individuals had sarco - osteoporosis using the sensitive criteria compared to standard criteria prevalence of sarcopenia , osteoporosis and sarco - osteoporosis by decade using standard or sensitive criteria . sarcopenia was more common in individuals age 80 + than 7079 and 6069  years ( p  <  0.01 ) regardless of criteria used ( a ) . 0.0001 ) individuals had sarcopenia using the sensitive criteria ( alm / reported historical tallest height ) compared to standard criteria ( alm / current height ) . similarly , osteoporosis was more common in individuals age 80 + than 7079 and 6069 ( p  < 0.001 ) regardless of criteria used ( b ) . significantly more ( p  <  0.0001 ) individuals had osteoporosis using the sensitive criteria ( lowest t - score from hip , lumbar spine and one - third radius ) compared to standard criteria ( lowest t - score of hip and lumbar spine only ) . sarco - osteoporosis was more common in individuals age 80 + than 7079 and 6069 ( p  <  0.05 ) regardless of criteria used ( c ) . significantly more ( p  < 0.0001 ) individuals had sarco - osteoporosis using the sensitive criteria compared to standard criteria osteoporosis prevalence increased with age ( p  <  0.001 ) with both the standard and  sensitive  criteria ( fig . the  sensitive  criteria identified more individuals with osteoporosis than the standard criteria ( p  <  0.0001 ) . overall , 17  % of this cohort was classified as osteoporotic with standard criteria whereas the sensitive criteria identified 29  % . sarco - osteoporosis prevalence increased with age ( p  <  0.05 ) using either the standard or  sensitive  criteria ( fig . the  sensitive  criteria identified more individuals with sarco - osteoporosis than the standard criteria ( p  <  0.0001 ) . the prevalence of osteoporosis and sarcopenia were similar ; however , the prevalence of sarco - osteoporosis was less than either ( p  <  0.0001 ) . specifically , 5  % of the entire cohort was classified as having sarco - osteoporosis with standard criteria whereas the sensitive criteria identified 11  % . a total of 304 individuals ( 158 females , 146 males ) age 60 and above were included in this cross - sectional analysis . their age and bmi ( mean , sd and range ) was 75.5 ( 7.5 ) years ( 6095 ) and 27.1 ( 4.9 ) kg / m ( 15.151.6 ) , respectively . the male cohort was slightly ( p  <  0.05 ) older . as could be expected , the males were taller and heavier ( p  <  0.001 ) than the females ; however , mean bmi did not differ . bmd t - score was lower ( p  <  0.05 ) at all sites in women . similarly , alm / ht was lower ( p  <  0.001 ) in women . participants were stratified by decade of age : 6069 ( n  =  89 ) ; 7079 ( n  =  119 ) ; and 80 + ( n  =  96).table 1study participant demographic dataage ( years)bmi ( kg / m)height loss ( cm)l1l4 t - scorefemoral neck t - scoretotal femur t - scoreone - third radius t - scorealm / height ( kg / m)female n  =  15874.5 * ( 7.0)27.1 ( 5.5)3.7 * ( 2.9)0.7 ( 1.7)1.5 * ( 0.9)1.0 * ( 1.1)1.9 ( 1.4)6.5 ( 1.0)male n  =  14676.5 ( 7.9)27.2 ( 4.0)4.5 ( 3.1)+0.9 ( 2.1)1.1 ( 1.0)0.7 ( 1.1)0.5 ( 1.1)8.1 ( 1.0)data are presented as mean ( sd)different than males : * p  <  0.05 ; p  < 0.001 study participant demographic data data are presented as mean ( sd ) different than males : * p  < 2 ) were apparent on the dxa image in virtually all ( 93  % ) of these volunteers . only 14 of 158 ( 9  % ) of the women and eight of 146 ( 5  % ) of these men had no apparent degenerative changes . as a result , lumbar spine t - scores deviated from normal to a lesser degree than in the radius in both men and women ( p  <  0.0001 ; fig .  3 ) . of those 14 individuals without obvious degenerative changes on their dxa image , 59  % were less than age 70.fig . examples of what were considered as  obvious  degenerative changes on the dxa images are presented here . the image on the left is a 70-year - old man in whom focal abnormalities at l2 and l3 are apparent . the individual vertebral body t - scores are consistent ; from l1 to l4 these values are + 1.1 , + 4.5 , + 4.2 and + 1.7 ; thus , a > 1 t - score difference is present between adjacent vertebrae . the 86-year - old female on the right has apparent degenerative changes at l2 , l3 and l4 with obvious osteophytes at l2 and l3 . t - score differences between adjacent vertebrae were observed with values from l1 through l4 being + 0.2 , + 1.7 , + 3.5 and + 4.1 , respectivelyfig . 3comparison of lumbar spine , femur neck and one - third radius t - scores in men and women . depicted are distribution curves ( using a normal continuous fit function ) of lumbar spine , femur neck and one - third radius t - scores in men ( a ) and women ( b ) . in both genders mean bmd t - scores were the higher at lumbar spine compared to the femur neck or the one - third radius site ( all p  <  0.0001 ) . mean bmd t - scores at the femur neck were higher than the one - third radius in females but lower in males ( all p  <  0.01 ; see table  1 for t - score values and their standard deviations ) . the broad range of lumbar spine t - scores in males is striking with values above + 5 in some men . this was not the case in the one - third radius site examples of spinal degenerative changes . examples of what were considered as  obvious  degenerative changes on the dxa images are presented here . the image on the left is a 70-year - old man in whom focal abnormalities at l2 and l3 are apparent . the individual vertebral body t - scores are consistent ; from l1 to l4 these values are + 1.1 , + 4.5 , + 4.2 and + 1.7 ; thus , a > 1 t - score difference is present between adjacent vertebrae . the 86-year - old female on the right has apparent degenerative changes at l2 , l3 and l4 with obvious osteophytes at l2 and l3 . t - score differences between adjacent vertebrae were observed with values from l1 through l4 being + 0.2 , + 1.7 , + 3.5 and + 4.1 , respectively comparison of lumbar spine , femur neck and one - third radius t - scores in men and women . depicted are distribution curves ( using a normal continuous fit function ) of lumbar spine , femur neck and one - third radius t - scores in men ( a ) and women ( b ) . in both genders mean bmd t - scores were the higher at lumbar spine compared to the femur neck or the one - third radius site ( all p  <  0.0001 ) . mean bmd t - scores at the femur neck were higher than the one - third radius in females but lower in males ( all p  <  0.01 ; see table  1 for t - score values and their standard deviations ) . the broad range of lumbar spine t - scores in males is striking with values above + 5 in some men . self - reported tallest height was greater than current stadiometer - measured height in 97  % ( 296/304 ) of study participants . males had a larger mean reported height loss than females ( 4.5 vs. 3.7  cm ; p  <  0.05 ; table  1 ; fig . use of reported tallest height in the alm / ht ratio reduced this value by a mean of 4.9  % in men and 4.4  % in women ( fig . the distribution curves ( using a normal continuous fit function ) for the amount of reported historical height loss ( a ) shows a mean of 4.5  cm in men and 3.7  cm in women . the variability of height loss is striking with some individuals reporting more than 10  cm of height loss . the negative values ( suggesting height gain ) are evidence of limitations of historical tallest height . the distribution curves of percentage change of using reported historical height loss instead of current height show that in both genders the mean alm / height ratio was decreased ( 4.4  % in females and 4.9  % in males ) historical height change and effect on alm / ht ratio . the distribution curves ( using a normal continuous fit function ) for the amount of reported historical height loss ( a ) shows a mean of 4.5  cm in men and 3.7  cm in women . the variability of height loss is striking with some individuals reporting more than 10  cm of height loss . the negative values ( suggesting height gain ) are evidence of limitations of historical tallest height . the distribution curves of percentage change of using reported historical height loss instead of current height show that in both genders the mean alm / height ratio was decreased ( 4.4  % in females and 4.9  % in males ) the prevalence of sarcopenia increased with age ( p  <  0.01 ) using either the standard or  sensitive  criteria ( fig . the  sensitive  criteria identified more individuals with sarcopenia than the standard criteria ( p  <  0.0001 ) . overall , 15  % of this cohort was classified as sarcopenic with standard criteria whereas the sensitive criteria identified 26  % .fig . 5prevalence of sarcopenia , osteoporosis and sarco - osteoporosis by decade using standard or sensitive criteria . sarcopenia was more common in individuals age 80 + than 7079 and 6069  years ( p  <  0.01 ) regardless of criteria used ( a ) . significantly more ( p  <  0.0001 ) individuals had sarcopenia using the sensitive criteria ( alm / reported historical tallest height ) compared to standard criteria ( alm / current height ) . similarly , osteoporosis was more common in individuals age 80 + than 7079 and 6069 ( p  < 0.001 ) regardless of criteria used ( b ) . significantly more ( p  <  0.0001 ) individuals had osteoporosis using the sensitive criteria ( lowest t - score from hip , lumbar spine and one - third radius ) compared to standard criteria ( lowest t - score of hip and lumbar spine only ) . sarco - osteoporosis was more common in individuals age 80 + than 7079 and 6069 ( p  <  0.05 ) regardless of criteria used ( c ) . significantly more ( p  <  0.0001 ) individuals had sarco - osteoporosis using the sensitive criteria compared to standard criteria prevalence of sarcopenia , osteoporosis and sarco - osteoporosis by decade using standard or sensitive criteria . sarcopenia was more common in individuals age 80 + than 7079 and 6069  years ( p  <  0.01 ) regardless of criteria used ( a ) . significantly more ( p  <  0.0001 ) individuals had sarcopenia using the sensitive criteria ( alm / reported historical tallest height ) compared to standard criteria ( alm / current height ) . similarly , osteoporosis was more common in individuals age 80 + than 7079 and 6069 ( p  < 0.001 ) regardless of criteria used ( b ) . significantly more ( p  <  0.0001 ) individuals had osteoporosis using the sensitive criteria ( lowest t - score from hip , lumbar spine and one - third radius ) compared to standard criteria ( lowest t - score of hip and lumbar spine only ) . sarco - osteoporosis was more common in individuals age 80 + than 7079 and 6069 ( p <  0.05 ) regardless of criteria used ( c ) . significantly more ( p  <  0.0001 ) individuals had sarco - osteoporosis using the sensitive criteria compared to standard criteria osteoporosis prevalence increased with age ( p  <  0.001 ) with both the standard and  sensitive  criteria ( fig . the  sensitive  criteria identified more individuals with osteoporosis than the standard criteria ( p  <  0.0001 ) . overall , 17  % of this cohort was classified as osteoporotic with standard criteria whereas the sensitive criteria identified 29  % . sarco - osteoporosis prevalence increased with age ( p  <  0.05 ) using either the standard or  sensitive  criteria ( fig . the  sensitive  criteria identified more individuals with sarco - osteoporosis than the standard criteria ( p  <  0.0001 ) . the prevalence of osteoporosis and sarcopenia were similar ; however , the prevalence of sarco - osteoporosis was less than either ( p  <  0.0001 ) . specifically , 5  % of the entire cohort was classified as having sarco - osteoporosis with standard criteria whereas the sensitive criteria identified 11  % . in this cross - sectional study of community - dwelling adults age 60 and older , the prevalence of osteoporosis , sarcopenia and sarco - osteoporosis was higher in older individuals . the prevalence of osteoporosis and sarcopenia was similar , whereas sarco - osteoporosis was less common . use of potentially more sensitive criteria ( i.e. , using tallest historical height instead of current height to define sarcopenia and including 1/3 radius bmd t - score in the definition of osteoporosis ) increased the prevalence of sarcopenia , osteoporosis and sarco - osteoporosis . this is not surprising as both degenerative changes , which elevate dxa - measured bmd , and reported height loss were present in virtually all of these individuals . to our knowledge , clearly , the prevalence of sarcopenia , osteoporosis and sarco - osteoporosis will vary depending on the population studied ( i.e. , prevalent hip fracture , included gender , age group and degree of frailty ) . as noted in the introduction , the prevalence of sarco - osteoporosis has been reported as high as 45  % in individuals who already suffered a hip fracture . other authors report percentages closer to those found in this study [ 19 , 30 ] . similar to the results reported here , most studies that divided participants by age observed a higher prevalence in older age groups [ 19 , 2931 ] . age is accepted as a major contributor to fracture risk [ 6 , 12 ] . it is probable that there are many risk factors  hidden within age  contributing to this increased risk ; evidence is increasing that sarcopenia is one such factor [ 19 , 2528 , 31 , 4547 ] . importantly , sarcopenia is closely linked to falls and increased risk of falling is a well - established contributor to fracture [ 10 , 26 , 48 , 49 ] . in addition to increasing falls risk , sarcopenia might also decrease bone strength by reducing mechanical loading to the skeleton . reduction of mechanical stimulation could result from decreased maximal force that weaker muscles produce and/or less time that the skeleton is loaded due to relative immobility [ 5053 ] . as such , the concept of  sarco - osteoporosis ,  seems likely to facilitate fracture risk estimation [ 27 , 28 , 31 ] . moreover , simple approaches such as described here ( radius bmd and use of historical height ) with potential to enhance diagnostic sensitivity for sarco - osteoporosis , may have direct clinical applicability in improving fracture risk estimation . consideration of clinical risk factors for fracture in addition to bmd has significantly changed osteoporosis treatment decision - making . however , potential limitation of frax ( www.shef.ac.uk/frax ) , relevant to this study is that only femoral neck ( not spine or radius ) bmd is considered . furthermore , sarcopenia , muscle function and falls are not able to be included in this algorithm given limitations of the observational cohorts used to derive frax [ 5456 ] . a second method to estimate fracture risk developed by the garvan institute ( www.garvan.org.au/bone-fracture-risk ) does include history and number of falls within the past year but no measure of muscle mass or function [ 10 , 11 ] . it could be argued that measurement of bmd at additional skeletal sites , i.e. , the forearm , is not necessary when bmd is measured at both the spine and femoral neck . however , lumbar spine bmd is elevated by degenerative changes that are present in virtually all older adults , 93  % in this study . for example , a study of 300 australian men and women age 60 and above found x - ray evidence of osteophytes in 69  % of all males and females , disc narrowing in 67  % and apophyseal osteoarthritis ( posterior element disease ) in 99  % of participants . another study of 600 japanese women age 60 and above found osteoarthritic changes in 96  % of individuals on lumbar spine x - rays . as could be expected , spinal degenerative changes increase lumbar spine bmd measured by dxa ; on average by 1524  % [ 5759 ] . additionally , femoral neck bmd measurement may also be elevated by degenerative changes . other femoral neck bmd measurement confounders include internal artifacts , fat panniculi and anatomic variations [ 60 , 61 ] . it seems likely that such confounders are one contributor to the less than ideal predictive capability of tools such as frax. as such , evaluations of potential approaches to enhance fracture prediction capability , potentially including forearm bmd measurement , are appropriate . limitations of this study include relatively small sample size and cross - sectional nature . furthermore , in this study sarcopenia could only be defined based on dxa measured alm / ht ratio , as muscle function data were not available in all cohorts used for this analysis . current consensus definitions for sarcopenia appropriately use both muscle mass and muscle function parameters as the combination of these measures improve the prediction of poor outcomes [ 20 , 22 ] . additionally , use of self - reported tallest height is inferior to serial height measurements over time as there is risk for recall errors and bias . two systematic reviews have identified a tendency in adults to overestimate historical tallest height , leading to a greater height loss than if prospectively measured . [ 62 , 63 ] despite this , self - reported height loss has apparent clinical applicability and , importantly , predicts clinical outcomes including vertebral fractures , mortality and morbidity [ 62 , 64 , 65 ] . future study to further define the accuracy of height recall , and an additional limitation is that data regarding prior fragility fracture or other outcomes for sarco - osteoporosis are not available in this study . future work is needed in longitudinal studies to evaluate the effect of sarco - osteoporosis diagnosis on risk for fragility fracture and also to explore the utility of using historical tallest height and radius bmd measurement on this diagnosis . in conclusion , sarco - osteoporosis is present in 10  % of adults over age 80 and the prevalence is higher in older people . using simple , but potentially more sensitive criteria , i.e. , adding the one - third radius bmd t - score and using tallest historical height , rather than current height , in the sarcopenia alm / height calculation identifies more individuals as potentially being at risk . assessment of both bone and muscle mass / function in older adults could potentially enhance fracture risk prediction ; research utilizing existing longitudinal studies in which bone and muscle status was carefully defined and fractures rigorously captured is needed to evaluate the potential utility of sarcopenia and sarco - osteoporosis consideration in fragility fracture risk assessment . although no causal attribution is possible in this analysis , sarco - osteoporosis may explain some of the increase in fracture risk currently related to  age . bjoern buehring , diane krueger , and neil binkley do not have any potential conflicts of interest .
backgrounda clinical need exists to improve identification of those who will sustain fragility fractures . 
 individuals with both osteoporosis ( op ) and sarcopenia ( sp ) , so - called  sarco - osteoporosis  ( sop ) , might be at higher fracture risk than those with op or sp alone . 
 approaches to facilitate sop identification , e.g. , use of tallest historical rather than current height and inclusion of radius bone mineral density ( bmd ) measurement , may be of benefit . 
 this study examined the effect of advancing age on sop prevalence with and without use of historical tallest height and radius bmd measurement.methodsadults age 60 + underwent dual - energy x - ray absorptiometry ( dxa ) bmd and total body composition measurement . op and sp 
 were defined using standard criteria : t - score 2.5 at the lumbar spine or hip and appendicular lean mass ( alm)/current height2 < 5.45  kg / m2 ( female ) and < 7.26  kg / m2 ( male ) . proposed 
 sensitive 
 sp criteria used historical tallest height instead of current height , while  sensitive  op criteria added the 1/3rd radius t - score . 
 the primary outcome was sop prevalence by decade ( 6069 , 7079 , 80+).resultsa total of 304 individuals ( 146  m/158  f ) participated . 
 op , sp and sop prevalence were higher in older adults and increased ( p  <  0.05 ) with the  sensitive  criteria . 
 sop prevalence was lower than that of op or sp and increased ( standard / sensitive ) criteria from 1.1  % / 4.5  % in the 6069  years age group to 10.4  % / 21.9  % in the 80 + years age group.conclusionssop prevalence is higher in older adults . 
 use of historical tallest height and 1/3rd radius bmd increases sop prevalence . 
 future studies need to assess whether having sop increases fracture risk and whether use of tallest height and/or one - third radius bmd improves fracture risk prediction .