Additive Effect of Sarcopenia and Anemia on the 10-Year Risk of Cardiovascular Disease in Patients with Type 2 Diabetes

Association between sarcopenia and hemoglobin level: a systematic review and meta-analysis

Background

Sarcopenia is a disease characterized by decreased skeletal muscle mass and function in elderly individuals. Decreased hemoglobin levels is a marker of anemia. According to reports, there may be an association between anemia and sarcopenia, but research is inconsistent. Therefore, this meta-analysis aims to explore the association between sarcopenia and low hemoglobin levels.

Methods

We searched PubMed, Embase, the Cochrane Library, Web of Science, Ovid, China National Knowledge Infrastructure (CNKI), and Wan Fang databases until September 2022. The present study included cross-sectional and case-control studies regarding low hemoglobin levels and sarcopenia. The studies were selected using inclusion and exclusion criteria. Studies were meta-analyzed by Review Manager 5.4 and Stata 16.0. We performed the heterogeneity test using the I 2 test. Subgroup analysis was carried out to explore the cause of heterogeneity. Egger test was used to evaluate publication bias.

Results

Out of 1,550 initial studies, 16 studies were meta-analyzed. Sarcopenia participants had significantly lower levels of hemoglobin than controls (MD = -0.53, 95% CI: -0.68 to -0.37, p < 0.001). Subgroup analysis, performed in China population reported lower hemoglobin levels in the sarcopenia population (MD = -0.49, 95% CI: -0.65 to -0.33, p < 0.001). And sarcopenia based on AWGS criteria reported lower hemoglobin levels (MD = -0.49, 95% CI: -0.65 to -0.33, p < 0.001). Among the population from hospitals and communities, patients with sarcopenia have lower hemoglobin levels.

Conclusion

Our meta-analysis found evidence that sarcopenia is associated with low hemoglobin levels. However, further large-scale prospective studies should be conducted in the future to further confirm our conclusions.

Systematic review registration

PROSPERO, CDR42024532252.

Effect of Sarcopenia on 10-Year Risk of Atherosclerotic Cardiovascular Disease in Patients with Type 2 Diabetes Mellitus

Objective

To investigate the impact of sarcopenia on the 10-year risk of atherosclerotic cardiovascular disease (ASCVD) among individuals with type 2 diabetes mellitus (T2DM).

Methods

This study included the clinical, laboratory, and body composition data of 1491 patients with T2DM who were admitted to the Department of Endocrinology and Metabolism at Tianjin Union Medical Center from July 2018 to July 2023. The China-PAR model was utilized to evaluate cardiovascular disease risk. Associations between ASCVD risk and various clinical parameters were analyzed, and the relationship between body composition parameters and ASCVD risk was assessed using logistic regression.

Results

The analysis revealed that T2DM patients with sarcopenia had a higher 10-year ASCVD risk compared to those without sarcopenia, with reduced muscle mass independently predicting an increased risk of cardiovascular disease. This association was significant among female T2DM patients, while male T2DM patients with sarcopenia showed a marginally higher median ASCVD risk compared to their non-sarcopenic counterparts. ASCVD risk inversely correlated with body muscle parameters and positively correlated with fat content parameters. Specifically, height- and weight-adjusted fat mass (FM, FM%, FMI) were identified as risk factors for ASCVD. Conversely, muscle parameters adjusted for weight and fat (ASM%, SMM%, FFM%, ASM/FM, SMM/FM, FMM/FM) were protective against ASCVD risk. These findings highlight the critical role of sarcopenia in influencing cardiovascular disease risk among Chinese patients with T2DM, as predicted by the China-PAR model.

Conclusion

This study highlights the importance of sarcopenia in T2DM patients, not only as an indicator of ASCVD risk, but possibly as an independent risk factor in this demographics.

Anemia and Its Connections to Inflammation in Older Adults: A Review

Anemia is a common hematological disorder that affects 12% of the community-dwelling population, 40% of hospitalized patients, and 47% of nursing home residents. Our understanding of the impact of inflammation on iron metabolism and erythropoiesis is still lacking. In older adults, anemia can be divided into nutritional deficiency anemia, bleeding anemia, and unexplained anemia. The last type of anemia might be caused by reduced erythropoietin (EPO) activity, progressive EPO resistance of bone marrow erythroid progenitors, and the chronic subclinical pro-inflammatory state. Overall, one-third of older patients with anemia demonstrate a nutritional deficiency, one-third have a chronic subclinical pro-inflammatory state and chronic kidney disease, and one-third suffer from anemia of unknown etiology. Understanding anemia's pathophysiology in people aged 65 and over is crucial because it contributes to frailty, falls, cognitive decline, decreased functional ability, and higher mortality risk. Inflammation produces adverse effects on the cells of the hematological system. These effects include iron deficiency (hypoferremia), reduced EPO production, and the elevated phagocytosis of erythrocytes by hepatic and splenic macrophages. Additionally, inflammation causes enhanced eryptosis due to oxidative stress in the circulation. Identifying mechanisms behind age-related inflammation is essential for a better understanding and preventing anemia in older adults.

Acute blood loss anemia in hospitalized patients is associated with adverse outcomes: An analysis of the Nationwide Inpatient Sample

BACKGROUND

Acute blood loss anemia is the most common form of anemia and often results from traumatic injuries or gastrointestinal bleeding. There are limited studies analyzing outcomes associated with acute blood loss anemia in hospitalized patients.

METHODS

The Nationwide Inpatient Sample (NIS) was analyzed from 2010 to 2014 (n = 133,809). The impact of acute blood loss anemia on in-hospital mortality, length of stay (LOS), healthcare cost, and disposition was determined using regression modeling adjusted for age, gender, race, and comorbidities.

RESULTS

Hospitalized patients with acute blood loss anemia had significantly higher healthcare cost (adj OR 1.04; 95% CI: 1.04-1.05), greater lengths of stay (adj OR 1.18; 95% CI: 1.17-1.18), and were less likely to be discharged home compared to the general medical population (adj OR 0.27; 95% CI: 0.26-0.28). Acute blood loss anemia was associated with increased risk for mortality in unadjusted models (unadj 1.16; 95% CI: 1.12-1.20) but not in adjusted models (adj OR 0.91; 95% CI: 0.88-0.94). When analyzing comorbidities, a "muscle loss phenotype" had the strongest association with mortality in patients with acute blood loss anemia (adj OR 4.48; 95% CI: 4.35-4.61). The top five primary diagnostic codes associated with acute blood loss anemia were long bone fractures, GI bleeds, cardiac repair, sepsis, and OB/Gyn related causes. Sepsis had the highest association with mortality (18%, adj OR 2.59; 95% CI: 2.34-2.86) in those with acute blood loss anemia.

CONCLUSIONS

Acute blood loss anemia is associated with adverse outcomes in hospitalized patients.

In people with type 2 diabetes, sarcopenia is associated with the incidence of cardiovascular disease: A prospective cohort study from the UK Biobank

AIM

To investigate the association of sarcopenia with cardiovascular disease (CVD) incidence in people with type 2 diabetes.

MATERIALS AND METHODS

A prospective cohort study with 11 974 White European UK Biobank participants with type 2 diabetes, aged 40-70 years, included. Sarcopenia was defined based on the European Working Group on Sarcopenia in Older People as either non-sarcopenic or sarcopenic. Outcomes included CVD, stroke, heart failure (HF) and myocardial infarction (MI). The association between sarcopenia and the incidence of outcomes was investigated using Cox proportional hazard models adjusted for sociodemographic and lifestyle factors. The rate advancement period was used to estimate the time period by which CVD is advanced because of sarcopenia.

RESULTS

Over a median follow-up of 10.7 years, 1957 participants developed CVDs: 373 had a stroke, 307 had an MI and 742 developed HF. Compared with non-sarcopenia, those with sarcopenia had higher risks of CVD (HR 1.89 [95% CI 1.61; 2.21]), HF (HR 2.59 [95% CI 2.12; 3.18]), stroke (HR 1.90 [95% CI 1.38; 2.63]), and MI (HR 1.56 [95% CI 1.04; 2.33]) after adjustment for all covariates. Those with sarcopenia had CVD incidence rates equivalent to those without sarcopenia who were 14.5 years older. Similar results were found for stroke, HF and MI.

CONCLUSIONS

In people with type 2 diabetes, sarcopenia increased the risk of developing CVD, which might occur earlier than in those without sarcopenia. Therefore, sarcopenia screening and prevention in patients with type 2 diabetes may be useful to prevent the complications of CVD.

Association of a Combination of Sarcopenia and Type 2 Diabetes with Blood Parameters, Nutrient Intake, and Physical Activity: A Nationwide Population-Based Study

This study aimed to investigate the association of sarcopenia and type 2 diabetes (T2D) with blood parameters, nutrient intake, and physical activity in older Korean adults. We divided 2952 participants into four groups: sarcopenic diabetes (SD), sarcopenia alone (S), diabetes alone (D), and non-sarcopenia and non-diabetes (NSND). Sarcopenia was defined by the appendicular skeletal muscle mass index, and T2D by fasting glucose levels or ongoing treatment. Blood samples were collected after an 8-h fast. Nutrient intake was assessed using a 24-h recall; physical activity was evaluated using a questionnaire. Compared with those in the other groups, the men in the S and SD groups showed significantly lower hemoglobin and hematocrit levels; vitamin D levels in men and parathyroid hormone levels in women were significantly lower in the SD group. Total energy, protein, and carbohydrate intakes were significantly lower in the SD and S groups than those in the D and NSND groups. Physical inactivity was significantly more common in the SD group (men: odds ratio, 1.61; women: odds ratio, 2.37) than in the NSND group. A combination of sarcopenia and diabetes as well as sarcopenia alone was associated with low levels of blood parameters, poor nutrient intake, and low physical activity.

Sarcopenia and Anemia in Elderly Koreans: A Nationwide Population-Based Study

Sarcopenia and anemia are common diseases in the elderly and are caused by various factors. In this study, the association between sarcopenia and anemia in an elderly Korean population was examined. The Korea Centers for Disease Control and Prevention's cross-sectional, nationally representative Korea National Health and Nutrition Examination Survey (KNHANES, 2008-2011) served as the source of the data for this study. Of the 2769 participants (1167 men and 1602 women) included in this study, a significant association was found between sarcopenia and anemia in the elderly in Korea. In Model 1, unadjusted for covariates, the prevalence of sarcopenia in all participants was 1.805 (95% CI 1.364-2.388) and 2.746 (95% CI 1.740-4.334) in men, and 1.494 (95% CI 1.045-2.138) in women. In Model 4, adjusted for all covariates, the prevalence of sarcopenia in all participants was 1.455 (95% CI 1.064-1.989) and 2.649 (95% CI 1.475-4.755) in men, but it was insignificant in women. While prior studies failed to consider variables such as exercise status and nutritional intake, this research incorporated these factors as covariates. Despite this comprehensive approach, this study still revealed an independent association between sarcopenia and anemia. Moreover, a significant association was uncovered among elderly men, with no corresponding association identified among women.

Hematologic toxicities, sarcopenia, and body composition change in breast cancer patients undergoing neoadjuvant chemotherapy

PURPOSE

Evaluation of body composition and sarcopenia status could provide evidence for more sensitive prediction of chemotherapy toxicities and support mitigation of the negative impacts of chemotherapy. This study evaluated associations among hematologic toxicities, sarcopenia, and body composition change in breast cancer patients undergoing neoadjuvant chemotherapy.

METHODS

This retrospective cohort study employed data from 298 breast cancer patients undergoing neoadjuvant chemotherapy. We evaluated two abdominal computed tomography scans before and after neoadjuvant chemotherapy to identify body composition change. As hematologic toxicities, severe (grade 3 or 4) anemia, neutropenia, and thrombocytopenia were assessed throughout the treatment period using Common Terminology Criteria for Adverse Events (version 5.0).

RESULTS

Participants experienced severe neutropenia (23.5%), anemia (7.1%), and thrombocytopenia (0.7%) during chemotherapy. After chemotherapy, the group with sarcopenia had double the anemia prevalence of the group without sarcopenia (p < 0.001). The group with anemia had significantly decreased skeletal muscle index (SMI, p = .0013) and subcutaneous fat index (SFI, p = .0008). Almost 50% of the sarcopenia group treated with an AC-T (weekly) regimen (combined anthracycline and cyclophosphamide followed by a weekly taxane) had neutropenia. Multiple logistic regression showed that the AC-T (weekly) group had higher neutropenia prevalence than other regimen groups.

CONCLUSION

Our findings of higher anemia prevalence in breast cancer patients with sarcopenia and decreased SMI and SFI after neoadjuvant chemotherapy provide evidence of a relationship between anemia and body composition change. Early screening and combined consideration of body composition change, sarcopenia status, and chemotherapy regimen could improve clinical outcomes.

Sarcopenia is an independent risk factor for all-cause mortality rate in patients with diabetic foot ulcers

Objective

This study aimed to determine whether sarcopenia affects the all-cause mortality rate of patients with diabetic foot ulcers (DFUs).

Research design and methods

The clinic-based observational study included 217 patients treated at the Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University during a 4-year period. All subjects underwent dual-energy X-ray absorptiometry to determine their body composition during hospitalization. Diagnosis of sarcopenia was based on the Baumgartner diagnostic criteria. Patients were followed up regularly by phone calls until April 1, 2019, and their survival status was recorded.Univariate and multivariate Cox risk ratio regression models were used to analyze factors influencing the all-cause mortality rate of patients with DFUs.

Results

Of the 217 patients, 158 people survived (82.7%), 33 died (17.3%), and 26 were lost to follow-up. The median follow-up time was 23 (Range 11-34) months. The majority of patients were male (68.6%), with a mean age of 67.29 ± 11.14 years. The 5-year survival rate was 68.3% and 45.9% for all study patients (n = 217) and sarcopenia patients (n = 81), respectively. Multivariate Cox risk regression model showed that age (HR 1.042[95%CI:1.006, 1.078], P = 0.021), sarcopenia (HR 5.051[95%CI:1.968, 12.961], P = 0.001), and serum creatinine (HR 1.007[95%CI: 1.003, 1.010], P < 0.001) were independent risk factors for all-cause mortality rate of patients with DFUs. Kaplan-Meier survival curve indicated that the survival rate of patients with sarcopenia was significantly lower than non-sarcopenia patients (P < 0.001).

Conclusions

Sarcopenia is an independent risk factor for all-cause mortality of patients with DFUs and hence an important prognostic factor for patients with DFUs. Active prevention and improvement of sarcopenia can potentially improve the survival outcomes of this patient population.

Relationship between serum creatinine to cystatin C ratio and subclinical atherosclerosis in patients with type 2 diabetes

INTRODUCTION

Sarcopenia index (SI), calculated by (serum creatinine/cystatin C)×100, is reported to be associated with sarcopenia. Few studies reported the association between SI and subclinical atherosclerosis. We evaluated the association between SI and subclinical atherosclerosis, assessed by brachial-ankle pulse wave velocity (baPWV).

RESEARCH DESIGN AND METHODS

One hundred seventy-four patients with type 2 diabetes were included in this cross-sectional study. The relationship between SI and baPWV was assessed by Pearson's correlation coefficient. To calculate area under the receiver operator characteristic (ROC) curve (AUC) of SI for the presence of subclinical atherosclerosis, which was defined as baPWV >1800 cm/s, ROC analysis was performed. Logistic regression analyses were performed to assess the effect of SI on the prevalence of subclinical atherosclerosis adjusting for covariates.

RESULTS

Mean age, duration of diabetes, baPWV, and SI were 66.9 (10.1) years, 17.7 (11.6) years, 1802 (372) cm/s, and 77.6 (15.8), respectively. There was an association between SI and baPWV (men; r=-0.25, p=0.001, and women; r=-0.37, p=0.015). The optimal cut-off point of SI for the presence of subclinical atherosclerosis was 77.4 (sensitivity=0.72, specificity=0.58, p<0.001, AUC 0.66 (95% CI: 0.57 to 0.74)). In addition, SI was associated with the prevalence of subclinical atherosclerosis (adjusted OR 0.95, 95% CI: 0.91 to 0.99, p=0.015).

CONCLUSIONS

SI is associated with the prevalence of subclinical atherosclerosis in patients with type 2 diabetes.

Bioelectrical Impedance Analysis for the Assessment of Body Composition in Sarcopenia and Type 2 Diabetes

Sarcopenia is emerging as a severe complication in type 2 diabetes (T2DM). On the other hand, it has been documented that nutritional aspects, such as insufficient protein or total energy intake, increase sarcopenia risk. The analysis of body composition is a relevant approach to assess nutritional status, and different techniques are available. Among such techniques, bioelectrical impedance analysis (BIA) is particularly interesting, since it is non-invasive, simple, and less expensive than the other techniques. Therefore, we conducted a review study to analyze the studies using BIA for body composition analysis in T2DM patients with sarcopenia or at risk of catching it. Revised studies have provided important information concerning relationships between body composition parameters (mainly muscle mass) and other aspects of T2DM patients’ conditions, including different comorbidities, and information on how to avoid muscle mass deterioration. Such relevant findings suggest that BIA can be considered appropriate for body composition analysis in T2DM complicated by sarcopenia/muscle loss. The wide size of the patients’ cohort in many studies confirms that BIA is convenient for clinical applications. However, studies with a specific focus on the validation of BIA, in the peculiar population of patients with T2DM complicated by sarcopenia, should be considered.