Sarcopenia and Frailty in Type 2 Diabetes Mellitus: An Overlooked Challenge

Chul-Hee Kim

doi:10.4093/dmj.2026.0339

Articles

Page Path: HOME > Diabetes Metab J > Volume 50(4); 2026 > Article

Editorial Sarcopenia and Frailty in Type 2 Diabetes Mellitus: An Overlooked Challenge: Chul-Hee Kim; Diabetes & Metabolism Journal 2026;50(4):666-668.
DOI: https://doi.org/10.4093/dmj.2026.0339
Published online: July 1, 2026

728 Views
54 Download

Division of Endocrinology and Metabolism, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea

Corresponding author: Chul-Hee Kim

Division of Endocrinology and Metabolism, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, 170 Jomaru-ro, Wonmi-gu, Bucheon 14584, Korea, E-mail: chkimem@schmc.ac.kr

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

prev next

Full Article

Download PDF

NOTES
REFERENCES
About this article

Sarcopenia and frailty are both age-related conditions that share significant common features and are associated with higher comorbidities and mortality in the general population. With the global increase in the aging population, these conditions have become major health concerns in patients with type 2 diabetes mellitus (T2DM). The relationship between sarcopenia, frailty, and diabetes is complicated as they often coexist and are related to other factors, especially aging.

Sarcopenia—low muscle strength and/or low muscle quantity/quality—is a comorbidity of diabetes with rising prevalence in recent decades [1]. Moreover, it is an independent predictor of incident all-cause mortality in older adults with T2DM [2–5].

Frailty, a state of increased vulnerability to stressors resulting from reduced physiologic reserve and impaired homeostatic capacity across multiple organ systems, is associated with decreased quality of life and increased risk of falls, disability, hospitalization, and mortality [6]. T2DM and frailty also frequently co-occur and are increasingly prevalent in older patients. Frailty not only affects the management of diabetes in older adults with T2DM, but is also associated with increased mortality in multiple settings [7,8].

Mortality is expected to be even higher when both conditions are present. Both sarcopenia and frailty are consistently associated with higher all-cause mortality, and their co-occurrence generally confers the highest risk [9]. Because definitions vary for sarcopenia and frailty, absolute hazard ratios differ by study, but the risk gradient (neither < one condition < both) is fairly consistent across various settings (community aging cohorts [9], oncology [10], and diabetes-related foot disease [11], among others). However, few studies have investigated the joint association of sarcopenia and frailty with mortality in older people with T2DM.

In this issue, Cengiz et al. [12] reported 5-year mortality in a cohort study of 447 T2DM patients aged 60 years or over after assessing muscle mass, strength, and frailty. The results showed that 11% had isolated sarcopenia, 22.4% isolated frailty, and 9.8% both. Co-existing sarcopenia and frailty significantly increased 5-year mortality risk; frailty alone had a hazard ratio of 2.59, while combined sarcopenia and frailty had a hazard ratio of 3.29 compared to those without these conditions.

This study reveals the current real-world situation of sarcopenia and frailty and their impact on mortality in patients with T2DM. However, it also has several limitations in research design and areas for improvement. First of all, the study population was not large, and was recruited from a single center, and thus is not representative of the general population. Second, the 5-year follow-up period may not be long enough for evaluation of median survival in chronic diseases. Third, further consideration of the diagnostic criteria for sarcopenia and frailty is crucial. The main limitations of studies up to now were non-uniform definitions, measurement heterogeneity, and imperfect construct validity across diabetes phenotypes. Different definitions of sarcopenia by different working groups (different entry points, cutoffs, and adjustment indices) yielded marked inconsistencies in prevalence and prognostic performance [13,14]. The frailty instrument chosen can also affect outcome associations in diabetes cohorts. The fatigue, resistance, ambulation, illnesses, and loss of weight (FRAIL) scale, which was used in this study, showed good diagnostic accuracy against the Fried phenotype in community-dwelling older adults with diabetes, but classified more people as frail than the Fried [15]. Studies comparing FRAIL-derived categories to a frailty index showed only moderate correlation, and outcome associations can differ by instrument [16].

In older diabetes patients, coexistence of diabetes and sarcopenia was associated with substantially higher frailty prevalence, and low muscle mass mediated part of the diabetes-frailty relationship, with synergistic interactions between diabetes and low strength/poor performance further increasing frailty odds [17]. This supports treating ‘sarcopenia+frailty’ as a higher-risk state than either alone, but it also underscores the construct overlap: low strength/poor performance influences both sarcopenia staging (European Working Group on Sarcopenia in Older People 2 [EWGSOP2]) and FRAIL scoring (via resistance/ambulation). Sarcopenia and frailty share core domains (weakness/slowness), so ‘double-positive’ groups can in part reflect definitional overlap rather than two independent pathologies; this is important when interpreting ‘combined phenotype’ mortality signals. Frailty captures multisystem vulnerability (energy dysregulation, neuroendocrine/inflammatory burden, comorbidity load, and reduced stress response), while sarcopenia captures a more specific end-organ manifestation closely tied to mobility limitation, falls, disability, and reduced cardiopulmonary reserve. Co-occurrence therefore often identifies patients with both systemic vulnerability and critical functional limitations, which plausibly increases death risk. It still remains unclear whether there is a specific diabetes-related pathway linking sarcopenia/frailty to mortality or if they are merely overlapping comorbid conditions. This needs to be elucidated more clearly in future studies.

In patients with T2DM, especially older adults and those with complications, screening for sarcopenia and frailty can identify patients at substantially higher mortality risk, including those with obesity, wherein sarcopenia may be under-recognized. The strongest phenotype signal in available data appears when sarcopenia/frailty co-occur and in sarcopenic obesity groups. Recently, a multicomponent intervention (16-week resistance exercise program, nutritional-educational sessions, optimization of diabetes care) showed improvement of frailty status and physical function in older people with T2DM [18]. We need more large-scale, long-term intervention studies to provide a strong supportive evidence base for functional outcomes and mortality impact.

In summary, although this study sounds the alarm about the current challenges of sarcopenia and frailty in T2DM patients, many unanswered questions remain. First of all, we urgently need a globally unified definition of sarcopenia and frailty. More large-scale, long-term follow-up studies in various populations are also needed. Furthermore, research on the mechanisms or pathways linking T2DM with sarcopenia/frailty could provide insight into future interventions.

NOTES

CONFLICTS OF INTEREST

Chul-Hee Kim has served as an international editorial board member of Diabetes & Metabolism Journal since 2023 but was not involved in the review process for this manuscript. The author declares no competing interests related to this work.

REFERENCES

1. Dai S, Shu D, Meng F, Chen Y, Wang J, Liu X, et al. Higher risk of sarcopenia in older adults with type 2 diabetes: NHANES 1999–2018. Obes Facts 2023;16:237-48.Article PubMed PMC PDF
2. Lin JA, Hou JD, Wu SY. Effect of sarcopenia on mortality in type 2 diabetes: a long-term follow-up propensity score-matched diabetes cohort study. J Clin Med 2022;11:4424.Article PubMed PMC
3. Takahashi F, Hashimoto Y, Kaji A, Sakai R, Okamura T, Kitagawa N, et al. Sarcopenia is associated with a risk of mortality in people with type 2 diabetes mellitus. Front Endocrinol (Lausanne) 2021;12:783363.Article PubMed PMC
4. Yamamoto S, Hashimoto Y, Takahashi F, Murai M, Yoshioka N, Saijyo Y, et al. Age-stratified associations of sarcopenic obesity with mortality in type 2 diabetes. J Cachexia Sarcopenia Muscle 2026;17:e70211.Article PubMed PMC PDF
5. Garcia-Tercero E, Villalon Rubio D, Belenguer-Varea A, Cunha-Perez C, Vina J, Tarazona-Santabalbina FJ, et al. Impact of sarcopenic diabetes on outcomes and mortality in older adults hospitalized for hip fracture: a nested case-control study within a real-world evidence cohort. Nutrients 2025;17:2616.Article PubMed PMC
6. Santulli G, Sabatelli G, Wang B, Savino M, Bruno FP, Jankauskas SS, et al. Interplay between frailty and cardiometabolic disorders: from pathophysiology to clinical implications. Cardiovasc Diabetol 2025;25:1.Article PubMed PMC PDF
7. Cobo A, Vazquez LA, Reviriego J, Rodriguez-Manas L. Impact of frailty in older patients with diabetes mellitus: an overview. Endocrinol Nutr 2016;63:291-303.Article PubMed
8. Ip WC, Shea YF, Chan TC, Lin OY, Chan WK, Law TC, et al. Clinical frailty scale as a predictor of 2-year mortality and associated risk factors in older diabetic patients. Geriatr Gerontol Int 2025;25:1732-40.Article PubMed PDF
9. Thompson MQ, Yu S, Tucker GR, Adams RJ, Cesari M, Theou O, et al. Frailty and sarcopenia in combination are more predictive of mortality than either condition alone. Maturitas 2021;144:102-7.Article PubMed
10. Sousa IM, Silva FM, das Virgens IPA, Costa EC, Fayh APT. Independent and joint association of sarcopenia and frailty with mortality in older patients with gastrointestinal cancer: a cohort study with prospective data collection. Support Care Cancer 2023;31:728.Article PubMed PDF
11. Hon KY, Bain M, Edwards S, Pena G, McMillan N, Fitridge R, et al. The association of sarcopenia and frailty in diabetes-related foot disease: a 3-year prospective evaluation. J Foot Ankle Res 2025;18:e70038.Article PubMed PMC
12. Cengiz BE, Ozer NT, Cengiz CB, Akgul YSS, Akin S. The concurrent challenges of sarcopenia and frailty: a 5-year mortality risk evaluation in geriatric patients with type 2 diabetes mellitus. Diabetes Metab J 2025;50:808-15.Article PubMed PMC PDF
13. Ye X, Chuan F, Li Y, Kang S, Tian W, Mei M, et al. Comparing the prognostic value of the old and new sarcopenia criteria from the Asian Working Group on Sarcopenia in older adults with type 2 diabetes: which set is more appropriate? Aging Clin Exp Res 2023;35:1917-26.Article PubMed PDF
14. Bai H, Liu Y, Zhang L, Song L, Pan Y, Long Z, et al. Sarcopenia as a predictor of negative health outcomes in patients with type 2 diabetes mellitus: a systematic review and meta-analysis. Diabetol Metab Syndr 2025;17:416.Article PubMed PMC PDF
15. Zeng L, Kong LN, Fang Q, Wang WX, Fan JL, Zhang XQ, et al. Diagnostic accuracy of the FRAIL scale for frailty screening in community-dwelling older adults with diabetes: a cross-sectional study. Geriatr Nurs 2023;52:115-20.Article PubMed
16. Wang J, Lee SY, Chao CT, Huang JW, Chien KL. Frailty assessment tools influence the outcome associations among patients with diabetes: a retrospective cohort study. JACC Asia 2025;5:799-810.Article PubMed PMC
17. Ao P, Yuan W, Ma Y, Tian H, Xu F, Wei S, et al. Sarcopenia increases the odds of frailty in older hospitalized diabetic patients. J Diabetes Complications 2026;40:109307.Article PubMed
18. Laosa O, Topinkova E, Bourdel-Marchasson I, Vellas B, Izquierdo M, Paolisso G, et al. Long-term frailty and physical performance transitions in older people with type-2 diabetes. The MIDFRAIL randomized clinical study. J Nutr Health Aging 2025;29:100512.Article PubMed PMC

Figure & Data

References

Citations

Citations to this article as recorded by

PubReader
ePub Link

Cite this Article

Cite this Article: export Copy Download Format; Close

Download Citation

Download a citation file in RIS format that can be imported by all major citation management software, including EndNote, ProCite, RefWorks, and Reference Manager.

Format: