Sarcopenia trunkal obesity diabetes inflection point ProJR: Managing sarcopenia and visceral fat driven vascular outcomes in patients with or without diabetes.
Managing sarcopenia and visceral fat driven vascular outcomes in patients with diabetes
Problem statement/Background
"Although obesity-related type 2 diabetes mellitus (T2DM) and sarcopenia have been increasing worldwide, the associations among visceral fat accumulation, skeletal muscle indices (mass, strength, and quality) and vascular outcomes in T2DM remain poorly investigated.
Quoted from reference 1: https://cardiab.
Even while it's easy to qualitatively spot individuals with reduced limb muscle mass and trunkal fat it is important to establish that improving limb muscle mass and trunkal fat utilizing diet and exercise strategies would improve cardiovascular outcomes in patients with diabetes mellitus.
AIM:
To improve vascular outcomes in patients at risk of diabetes evidenced by their increased visceral fat and reduced muscle mass and strength.
OBJECTIVES:
To assess various clinical and investigational characteristic of patients with sarcopenia and diabetes in relation to their outcomes.
To analyse patient outcomes based on morbidity (physical, social 7 psychological limitations) & mortality.
PATIENTS AND METHODS:
PLACE OF STUDY: Department of general medicine
STUDY PERIOD: November 2022-October 2024
STUDY DESIGN: Non experimental (observational) qualitative Prospective Study
SAMPLE SIZE: 50 patients
INCLUSION CRITERIA:
Patients of any gender above or equal to 18yrs of age at the time of presentation.
Patients presenting with a combination of sarcopenia and increased visceral fat with or without diabetes mellitus.
EXCLUSION CRITERIA:
1.Patients below 18 yrs of age (minors)
2.Patients not capable of giving consent (mentally ill patients)
3.Patients not willing to participate in study (non-consenting patients)
PROFORMA (data to be captured)
Demographics
Anthropometric indicators of sarcopenia and increased visceral fat:
Mid arm circumference
Abdominal circumference
Functional indices:
Hand grip
Biceps power
On investigation:
FBS, PPBS, Hba1c
Chest X-ray -PA view
ECG
2D ECHO
CBP
Serum creatinine
Patient reported outcomes:
Daily exercise (in terms of routine activities)
Daily diet in the form of meal images captured before consumption
Blood sugar outcomes in terms of weekly FBS PPBS and Hba1c every three months
Vascular outcomes suggested by symptoms and signs of vascular events involving different organ systems supplied by macro and micro vessels such as cardiac, neurological, renal, ocular, cutaneous etc.
Links to a spectrum of detailed individual patient PaJR proforma data and outcomes over few years: 
MASTER CHART WITH LINKS TO PATIENTS E-LOG
Link To Master Chart:
PATIENT INFORMATION SHEET
English:
Telugu:
Template of this "patient information sheet" is borrowed from this website:
And modified accordingly to my thesis topic.
REFERENCES:
1) Murai, J., Nishizawa, H., Otsuka, A. et al. Low muscle quality in Japanese type 2 diabetic patients with visceral fat accumulation. Cardiovasc Diabetol 17, 112 (2018). https://doi.org/10.1186/
Detailed 2021 batch tentative thesis titles here: http://medicinedepartment.
[07-10-2025 16.26] cm: Afternoon session:
45M diagnosed diabetes on June 2025
Lean phenotype without trunkal obesity
Was initially evaluated in ESI hospital Choutuppal and started on glimiperide, metformin, sitagliptin and later even mixtard insulin was added.
Currently admitted due to altered sensorium and some vague history of hypoglycemia two days back with MRI showing csvd in the pons.
His son 24M was diagnosed diabetes and is on insulin mixtard twice a day since October 2024!
@pajr.in CEO, NHS Endocrinologist this is also one of the patients who's Hba1c has been documented to break the Narketpally turbilatex ceiling of 8 with a value of 9! There's another one @Akash Deep Kims 2023 knows had 10 and there's another one with 13 admitted today! Suddenly a breakthrough cluster in our Narketpally Hba1c!
So @cr he'll get into 3 ProJRs:
1)https://pajrcasereporter.blogspot.com/2025/08/projr-biochemistry.html?m=1
2)https://medicinedepartment.blogspot.com/2022/07/preliminary-draft-synopsis-plan.html?m=1
3)https://pajrcasereporter.blogspot.com/2025/08/projr-csvd.html?m=1
[07-10-2025 16.30] cm: Afternoon session:
Here's the other 45M with denovo diabetes, Hba1c of 13 and DKA!
He's also quite lean without trunkal obesity and I hope to share his details tomorrow
[09-10-2025 10.35] cm: OPD now:
60M with polyarthritis and bilateral hand involvement since one month
[09-10-2025 11.31] huai1: Excellent and very insightful clinical question. This case touches on several key concepts in modern metabolic medicine and sarcopenia research. Let's break it down.
### 1. Epidemiological Context: Pear-Type Obesity in Indians
Your observation is astute. **Pear-type obesity (gynoid obesity)** is relatively less common in the Indian population compared to **apple-type obesity (android/central obesity)**.
* **The General Indian Phenotype:** Indians have a strong genetic and phenotypic predisposition to central adiposity. This means even at lower BMIs, they tend to accumulate fat viscerally (around the abdomen and internal organs). This is a key driver of the high prevalence of metabolic syndrome, insulin resistance, and type 2 diabetes in India.
* **Epidemiology of Gynoid vs. Android Obesity:**
* **Android (Apple) Pattern:** This is the **dominant pattern** in both Indian men and women. It is strongly associated with cardiometabolic risk.
* **Gynoid (Pear) Pattern:** While less common, it is certainly present, more so in pre-menopausal women. The fat stored in the hips and thighs (subcutaneous gluteofemoral fat) is actually considered more metabolically "safe" and may even have some protective effects against diabetes and cardiovascular disease *compared to visceral fat*.
* **Conclusion:** In a 45-year-old Indian woman, central obesity would be the statistically more likely finding. However, the presence of a pear-shaped body type does not rule out significant metabolic disease, especially when compounded with other factors like a 2-year history of diabetes. The diabetes itself suggests an underlying insulin resistance, which may be present even in a gynoid phenotype, indicating that her metabolic picture is complex.
### 2. The Dynapenia vs. Sarcopenia Paradox: Counters the Hypothesis?
This is the core of your clinical insight, and it's a fantastic point. The PG's observation that the patient has **preserved muscle strength** despite the **arm bulk being mostly fat** seems to contradict the classic model. Let's dissect why it doesn't necessarily counter the hypothesis but rather refines our understanding of it.
The classic hypothesis is: **Dynapenia (loss of muscle strength and power) → Sarcopenia (loss of muscle mass and quantity).**
Your case presents a more nuanced scenario:
**A. The "Fat Masking" and "Muscle Quality" Concept:**
The key here is to differentiate between:
* **Muscle Quantity (Mass):** The amount of muscle tissue.
* **Muscle Quality:** The *functionality* of the muscle per unit of mass (including contractile properties, fat infiltration, mitochondrial function).
* **Muscle Strength:** The measurable output.
In this patient:
1. **High Adiposity:** The "bulk" is largely fat. This means her actual *muscle quantity* might already be lower than it appears (**relative sarcopenia**). The fat is masking the loss of pure muscle tissue.
2. **Preserved Strength:** The fact that she is stronger than the PG suggests that the *muscle quality* within her remaining muscle tissue is still quite good. She has not yet developed significant **dynapenia**.
3. **The Trajectory:** This patient fits a different pathway, often seen in obesity and diabetes: **Sarcopenia (hidden by fat) may be *preceding* Dynapenia.** The loss of muscle mass is happening due to factors like inactivity, poor nutrition, or diabetic myopathy, but the neural drive and quality of the remaining muscle are still sufficient to generate strength.
**B. The Impact of Diabetes (Diabetic Myopathy):**
A 2-year history of diabetes is highly relevant. Diabetes accelerates muscle loss through:
* **Insulin Resistance in Muscle:** Impairs protein synthesis.
* **Inflammation:** Promotes muscle breakdown.
* **Mitochondrial Dysfunction:** Reduces energy production and muscle performance.
* **Intermuscular Fat Infiltration (Myosteatosis):** This is a critical concept. Fat starts to infiltrate the muscle tissue itself, degrading its quality. This process often happens *before* a significant loss of strength becomes apparent.
**Conclusion on the Hypothesis:**
The case does not counter the hypothesis but illustrates that the relationship between mass and strength is not always linear, especially in the context of obesity.
* **The hypothesis "Dynapenia precedes Sarcopenia" is often true in aging-related frailty.**
* **In obesity and diabetes, we often see a different sequence:**
1. **Stage 1: Loss of Muscle Quality & Hidden Mass Loss.** Muscle mass begins to decline and is infiltrated by fat (myosteatosis), but absolute strength is maintained due to compensation and the masking effect of overall body fat. **This is the stage your patient appears to be in.**
2. **Stage 2: Onset of Dynapenia.** As muscle quality deteriorates further and neural adaptations fail, strength and power begin to decline noticeably.
3. **Stage 3: Overt Sarcopenic Obesity.** The combination of low muscle mass/strength and high fat mass becomes clinically evident and debilitating.
### Summary for the Patient (45F, Pear-shaped, Diabetic):
1. **Phenotype:** While pear-shaped obesity is less common in Indians, it does not confer complete metabolic protection, as evidenced by her diabetes.
2. **Muscle Status:** She likely has a condition of **"Normal Strength but Reduced Muscle Quality"** or early **Sarcopenic Obesity**. The bulk is deceptive; the functional muscle tissue is likely less than it seems.
3. **Clinical Implication:** This is a critical window for intervention. Her preserved strength is a **positive asset**.
* **Management should aggressively include:** **Resistance (Strength) Training.** This is the most powerful tool to combat both sarcopenia and dynapenia. It will help build/maintain muscle mass, improve muscle quality, and enhance insulin sensitivity.
* **Combine with:** Adequate dietary protein and optimal glycemic control to create a synergistic effect for muscle health.
In essence, you have identified a patient on a trajectory towards functional decline, but one who is at a stage where targeted intervention can have a profound impact on preserving her mobility and metabolic health for years to come.
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