Sarcopenia, first defined by Irwin Rosenberg in 1988 as an age-related decline in skeletal muscle mass and function, has since been further characterized by Baumgartner through the evaluation of appendicular lean mass adjusted for height. It affects approximately 6–22% of older adults and involves the loss of muscle mass and/or strength, leading to physical impairment and frailty1. While sarcopenia is closely linked to frailty—a condition characterized by increased vulnerability to stressors due to reduced physiological reserve—they are not synonymous. Both sarcopenia and frailty have been associated with adverse clinical outcomes, such as increased risk of decompensation and higher mortality rates among patients on waitlists for organ transplantation. Notably, sarcopenia can also occur in individuals younger than 65 years, due to various pathological conditions, emphasizing the need for assessment methods that evaluate both muscle mass and function2.Globally, the rising burden of diabetes mellitus (DM) presents a significant challenge to healthcare systems, with around 9% of the world’s population diagnosed with diabetes—90% of whom have type 2 diabetes mellitus (T2DM). Older adults often mistake fatigue and weight loss as normal aspects of aging, which can delay diagnosis and treatment.3 Research has shown that engaging in muscle-strengthening activities can reduce the risk of developing T2DM. Recently, sarcopenia has been formally recognized as a diagnosable condition in the International Classification of Diseases (ICD-10), encouraging clinicians to diagnose and manage it more effectively, particularly in older adults.4The relationship between sarcopenia and diabetes is complex and increasingly recognized worldwide. Individuals with diabetes have a higher susceptibility to sarcopenia compared to non-diabetics. Diabetes, a chronic condition impairing the body’s ability to regulate blood glucose levels, can cause damage to blood vessels and nerves, which in turn affects muscle health, leading to reductions in muscle mass and strength. Additionally, diabetes-induced hormonal changes and chronic inflammation may accelerate the development of sarcopenia. Early diagnosis and management of diabetes are crucial to preventing sarcopenia and its associated complications. Skeletal muscle damage in diabetic patients has emerged as a novel concern due to increased life expectancy among this population. Sarcopenia in diabetes is linked to higher rates of hospitalization, cardiovascular events, and mortality. It is characterized by a gradual, widespread loss of muscle mass and performance, with muscle strength declining as part of the aging process. Insulin resistance and oxidative stress play critical roles in sarcopenia’s pathophysiology, alongside vascular changes, chronic inflammation, and lipid accumulation within muscle tissue—hallmark features of diabetes. Studies suggest that the prevalence of sarcopenia in diabetic individuals is two to three times greater than in those without diabetes. Encouragingly, sarcopenia is often reversible, with musculoskeletal rehabilitation capable of restoring physical capacity. Both sarcopenia and T2DM increase in prevalence with age, significantly contributing to frailty, hospitalizations, disability, and premature mortality.5 Various mechanisms underlie the high prevalence of sarcopenia in T2DM, including impaired glycemic control and hyperglycemia-induced catabolism leading to decreased muscle function. The growing focus on sarcopenia in T2DM stems from its substantial impact on quality of life and the recognition of frailty and sarcopenia as emerging complications alongside traditional microvascular and macrovascular diseases. Research attention centers on the association between sarcopenia and diabetes characteristics such as metabolic control, disease duration, and complication status. Additionally, diet and glucose-lowering medications may influence sarcopenia’s progression.6 Understanding these factors is essential for identifying individuals at risk and implementing appropriate interventions to mitigate sarcopenia’s impact, ultimately improving health outcomes for older adults with T2DM. This paper explores the intricate association between sarcopenia and type 2 diabetes, highlighting the importance of integrated clinical approaches.

AIM

To evaluate the prevalence of sarcopenia in patients with type 2 diabetes mellitus (T2DM).

This cross-sectional study was conducted over a period of 18 months starting from April 2023, following the acceptance of Institutional Ethics Committee (IEC) approval. The research took place in the Department of General Medicine and the Department of Radiology at Mahatma Gandhi Medical College & Hospital, Jaipur. Ethical clearance was obtained from the Institute Ethics Committee prior to commencement, and written informed consent was secured from all participants before their enrollment in the study. The inclusion criteria comprised men and women aged between 18 and 65 years with a diagnosis of type 2 diabetes mellitus (T2DM) for at least one year, currently receiving treatment at MGMC. Patients who declined to provide consent were excluded, as were those with other chronic illnesses, including type 1 diabetes, uncontrolled or severe diseases, and infections. Additionally, individuals using medications that directly affect body composition (excluding diabetes treatments), illicit drug users, patients with a body mass index (BMI) greater than 35 kg/m² or lower than 18 kg/m², and those on hormonal or nutritional supplements were excluded. Professional athletes, immobilized patients, or those with impaired mobility were also excluded to ensure a homogenous study population.

Table 1: Age wise comparison of the study

The age-wise comparison between the case and control groups demonstrated no statistically significant difference, with a p-value of 0.36. The mean age of participants in the case group was 43.19 ± 12.62 years, while in the control group, it was 41.27 ± 8.43 years.

Table 2: Gender wise comparison of the study

Females constituted 53.8% (28 out of 52 participants), •               Males constituted 46.2% (24 out of 52 participants).

Table 3: BMI wise comparison of the study

The Body Mass Index (BMI) comparison between the case and control groups revealed a statistically significant difference (p = 0.001). The mean BMI in the case group was 28.57 ± 5.40, which falls in the overweight to obese range, whereas the control group had a significantly lower mean BMI of 21.33 ± 1.99, within the normal range.

Table 4: History of fall in the study

The study shows a significantly higher incidence of falls in the case group, with 36.5% (n = 19) of individuals reporting a history of falls compared to only 5.8% (n = 3) in the control group. This difference is statistically significant (p = 0.001), indicating a strong association with sarcopenia and increased fall risk.

Table 5: Hand grip strength wise comparison of the study

The comparison of hand grip strength between the case and control groups revealed a statistically significant reduction in the case group (mean = 23.21 ± 3.73) compared to the control group (mean = 29.29 ± 6.01), with a p-value of 0.001.

Table 6: Waist circumference wise comparison of the study

The study reveals a statistically significant difference in waist circumference between the case and control groups, with the mean waist circumference in cases being 105.0 ± 13.08 cm compared to 84.67 ± 5.64 cm in controls (p = 0.001).

Table 7: Muscle thickness wise comparison of the study

The muscle thickness was significantly lower in the case group (26.29 ± 2.57 mm) compared to the control group (30.05 ± 5.17 mm), with a p-value of 0.001, indicating a statistically significant difference.                              

Table 10: Gender wise analysis for Female patients

Table 11: Gender wise analysis for Male patients

Age, a critical factor in disease outcomes, showed no significant difference between cases (mean age 43.19 years) and controls (41.27 years), with a p-value of 0.36. This suggests effective age matching between groups, minimizing confounding bias. Although age ranges varied slightly, the mean values confirmed comparable cohorts.

Gender differences in disease epidemiology and response to physiological stressors are well-documented. In this study, 53.8% of the case group were female and 46.2% were male, while the control group had 53.8% males and 46.2% females. The symmetric gender distribution across groups suggests a well-balanced sample, minimizing gender-related confounding. Given known sex-based differences in fat distribution, hormone levels, and muscle metabolism, this balance enhances the reliability of metabolic and musculoskeletal outcome comparisons.7

BMI is a critical marker of adiposity and is closely associated with metabolic syndrome, diabetes, cardiovascular risk, and musculoskeletal conditions. The mean BMI in the case group was 28.56 (SD = 5.40), which falls in the overweight-toobese category, while the control group had a significantly lower mean BMI of 21.33 (SD = 1.99), considered normal. The p-value for this difference was 0.001, indicating strong statistical significance. The significantly elevated BMI in the case group highlights obesity's central role in metabolic and musculoskeletal dysfunction, reinforcing the need for targeted public health interventions. Zengin A, et al., did a study where they reported the prevalence of sarcopenia in older diabetics (>45 years) of 31% among males and 20% among females using the AWGS 2014 criteria.8

The most striking observation in this study is the 100% prevalence of diabetes in the case group and 0% in the control group. This categorical separation firmly establishes diabetes mellitus as a defining criterion for the case cohort.  Hand grip strength (HGS) is a validated indicator of overall muscular function and a predictor of frailty, morbidity, and mortality. The mean HGS in the case group was significantly lower (23.21 kg) compared to the control group (29.29 kg), with a p-value of 0.001.  Lower HGS in diabetic individuals has been attributed to insulin resistance, chronic inflammation, and mitochondrial dysfunction.9 Sarcopenia is highly prevalent in diabetics and manifests earlier than in non-diabetics, as muscle protein degradation outpaces synthesis. These findings are consistent with global data linking decreased grip strength with metabolic syndrome, cardiovascular disease, and poor functional outcomes.10 Waist circumference (WC) is a surrogate for visceral adiposity, and is a superior predictor of metabolic risk than BMI. The present study shows significantly higher WC in the case group (105.0 cm) compared to controls (84.67 cm), with a  p-value of 0.001. Excess abdominal fat contributes to insulin resistance, increased inflammatory markers, and metabolic syndrome.11 WC is also associated with adverse lipid profiles and higher HbA1c, both of which were deranged in this cohort’s case group.

Central obesity, as evidenced by elevated WC, is a core component of the pathophysiological cascade leading to type 2 diabetes, sarcopenic obesity, and osteoporosis-related complications.12 Muscle thickness serves as an indicator of skeletal muscle mass, which is crucial in diagnosing sarcopenia and assessing physical resilience. The case group had significantly lower muscle thickness (26.29 mm) compared to the control group (30.05 mm), with a highly significant p-value of 0.001.  Muscle atrophy in individuals with diabetes is well-documented, with contributing factors including insulin resistance, mitochondrial dysfunction, chronic low-grade inflammation, and decreased physical activity.13 these alterations can reduce protein synthesis and accelerate muscle breakdown, leading to decreased muscle mass and function.  The findings are consistent with previous literature reporting sarcopenia in diabetic populations, which increases risks for falls, fractures, and loss of independence.

Yu M et al., there was statistically significant difference between nonsarcopenia & sarcopenia groups as the p value for handgrip strength, waist circumferenece and appendicular skeletal muscle index was <0.001 each respectively.14

In this study, the incidence of fracture risk was significantly higher among cases (36.5%) compared to controls (5.8%), with a p-value of 0.001. This strong statistical difference underscores a considerable vulnerability to skeletal fragility in diabetic individuals.

Diabetes is associated with reduced bone mineral density (BMD), impaired bone quality, and increased risk of fragility fractures.15 Hyperglycemia induces formation of advanced glycation end-products (AGEs), which deteriorate bone collagen and structure. Furthermore, impaired renal function and reduced vitamin D levels in diabetics also contribute to compromised bone metabolism. These results align with global findings and highlight the importance of integrated bone health assessment in managing diabetic patients.16

In the case group, males showed significantly higher hand grip strength than females (p = 0.01), consistent with known sex-based muscular differences, while waist circumference and muscle thickness did not differ significantly. In contrast, the control group exhibited no significant gender differences across all parameters, suggesting that sex-related variations may be more pronounced in disease contexts. These findings highlight the role of underlying pathology in amplifying physiological disparities between genders.

While hemoglobin and platelet levels showed non-significant elevations, the significantly higher HbA1c in the case group confirms poor glycemic control and reflects underlying chronic metabolic stress in diabetes. Du Y et al., in their study found that, HbA1c & Hb both showed nonsignificant association when difference was seen between sarcopenia group and nonsarcopenia group as the p value was 0.160 and 0.646 respectively.17

Lipid analysis showed significantly higher HDL and LDL levels in diabetic cases, while total cholesterol and triglycerides remained comparable between groups. The paradoxical HDL elevation in cases may stem from pharmacological or lifestyle interventions, deviating from typical diabetic lipid profiles. Elevated LDL aligns with atherogenic dyslipidemia, underscoring cardiovascular risk in diabetes. Wang et al., in his study demonstrated that TG/HDL-C ratio was negatively associated with sarcopenia occurrence rate in community-dwelling Chinese adults. Hermans MP et al., found that, the atherogenic dyslipidemia ratio [log (TG)/HDL-C] was significantly related to skeletal sarcopenia in T2DM females of Japan.18

Total protein, albumin, and globulin levels were significantly higher in diabetic cases, suggesting early inflammatory or metabolic adaptations rather than protein-losing states. Elevated globulins may point to subclinical inflammation or hepatic changes commonly seen in diabetes.

Our study highlights a strong association between type 2 diabetes mellitus and sarcopenia, marked by reduced muscle strength, thickness, and elevated central obesity. Poor glycemic control and altered lipid and protein profiles further support the metabolic basis of sarcopenia in diabetics. Although not influenced by age or gender, sarcopenia correlated with diabetes-related complications like neuropathy. Early identification and targeted interventions can reverse sarcopenia and reduce morbidity. Routine sarcopenia screening in diabetic care is essential to improve long-term outcomes and quality of life.

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