Introduction

Cardiovascular disease (CVD) is a major risk factor for diabetes, and muscle strength is an emerging risk factor for CVD. It is known that patients with type-2 diabetes mellitus (T2DM) have reduced muscle strength. Studies have demonstrated a prevalence between 7% to 29.3% for sarcopenia in T2DM patients, this could potentially be associated with an excess CVD risk in people with T2DM.

Aim

To determine the association of sarcopenia with incident CVD in patients with T2DM. The association of sarcopenia components (grip strength, muscle mass and gait speed) with the incident CVD was also determined.

Patient Profile

• White European participants from the UK Biobank cohort study who had T2DM (n=11974; age: 40-70 years).

  Methods

  Study Design

• A prospective cohort study.

  Assessments

• Sarcopenia was ascertained, based on the measurements of grip strength, muscle mass and gait speed.
• CVD (fatal, and non-fatal) was ascertained using medical records.
• Cox proportional hazard models were employed to determine the association between sarcopenia and incident CVD. The results were adjusted for various confounders with two models that included an increasing number of covariates:
  • Model 1 (the minimally adjusted model): Included age, sex, deprivation index and education.
  • Model 2 (the fully adjusted model): The model was further adjusted for processed meat consumption, smoking status, alcohol intake, total sedentary time, total physical activity and T2DM duration.
  • Sensitivity analysis (Model 3): This model further accounted for BMI.
• Non-sarcopenia served as the reference group for all analyses.

Outcomes

• Incidence of CVD, stroke, heart failure (HF) and myocardial infarction (MI).

  Results

• The mean age of the study participants was 59.8 years. Overall, 1957 study participants developed CVD during a median follow-up of 10.7 years: 373 had a stroke, 307 had an MI and 742 developed HF.
• As per a minimally adjusted model, individuals with sarcopenia had a two-fold higher risk of incident CVD [hazard ratio (HR): 2.04; 95% confidence interval (CI): 1.76 to 2.37]. As per a fully adjusted model, individuals with sarcopenia had an 89% higher risk of CVD (HR:1.89; 95% CI: 1.61 to 2.21).
• The magnitude of association attenuated slightly when results were adjusted for body mass index (BMI) but remained statistically significant (HR:1.77; 95% CI: 1.51 to 2.07).
• The propensity score-matching results revealed that T2DM patients with sarcopenia vs. those without, had a two-fold higher risk of CVD (HR: 2.01; 95% CI: 1.33 to 3.16).
• After adjusting for all the variables, T2DM patients with sarcopenia vs. those without had higher risks of CVD (HR: 1.89; 95% CI: 1.61 to 2.21), HF (HR: 2.59; 95% CI: 2.12 to 3.18), stroke (HR:1.90; 95% CI: 1.38 to 2.63), and MI (HR: 1.56; 95% CI: 1.04 to 2.33).
• The magnitude and association between sarcopenia and incident stroke, HF and MI was on similar lines as CVD, for all the models.
• The associations of weak grip and slow walking pace with incident CVD were on similar lines as of sarcopenia.
• As per the fully adjusted model, individuals with weaker grip strength vs. those with normal grip strength had a higher risk of CVD (HR: 1.85; 95% CI: 1.58 to 2.17), stroke (HR: 1.82; 95% CI: 1.32 to 2.53), HF (HR: 2.54; 95% CI: 2.07 to 3.12) and MI (HR: 1.59; 95% CI: 1.06 to 2.37).
• Similarly, individuals with a slow walking pace vs. those with a normal walking pace had a higher risk of CVD (HR: 1.92; 95% CI: 1.64 to 2.24), stroke (HR: 1.84; 95% CI: 1.33 to 2.55), HF (HR: 2.63; 95% CI: 2.15 to 3.22) and MI (HR: 1.59; 95% CI: 1.06 to 2.38).
• The magnitude of these associations attenuated slightly yet remained significant after accounting for BMI.
• Low muscle mass was not associated with incident risk of CVD in any of the models but was associated with a high risk of CVD when the analysis was adjusted for BMI (HR:2.12; 95% CI: 1.09 to 4.11).
• Low muscle mass was associated with incident stroke on similar lines in all the models, with a 3.4-fold higher risk in the fully adjusted model (HR: 3.39; 95% CI: 1.25 to 9.19). Low muscle mass was not associated with incident HF. The association between low muscle mass and incident MI could not be demonstrated due to the small number of participants.
• The rate advancement period (RAP) amongst study participants with sarcopenia vs. non-sarcopenia were as per table1.

Table 1: The RAP among individuals with sarcopenia vs. non-sarcopenia

• The RAP of 14.5 years for CVD incidence implied that people with sarcopenia probably had the same CVD incidence as those without sarcopenia who were 14.5 years older.

Conclusions

• Sarcopenia increased the risk of incident CVD in individuals with T2DM, which might occur earlier than in those without sarcopenia.
• Screening for sarcopenia and prevention is therefore essential in patients with T2DM to mitigate the risk of CVD.

Diabetes Obes Metab. 2024;26:524–531.